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 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.
This was an unannounced inspection. Our previous inspection of the home on 31 March 2013 found that people’s needs were not always assessed and care was not always planned and delivered to meet their assessed needs. We told the provider that they must make improvements to protect people from the risks of unsafe care. We required that the provider send us a report by 29 May 2014 detailing the improvements they would make to keep people safe. We did not receive this report and the provider was unable to offer an explanation as to why this report had not been sent. During this inspection we found that improvements had not been made.
The home provides accommodation and personal care for up to 70 older people some of whom have dementia care needs. At the time of inspection 41 people were living at the home. As a condition of registration the service must have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The service had not had a registered manager since 30 December 2013. A manager had been appointed and the provider told us that they would apply to become the registered manager.
People were not protected against the risks of receiving unsafe care as the provider had not assessed, planned or delivered care to ensure people’s welfare and safety. People’s bed rails were not fitted correctly to reduce the risk of injury or them becoming trapped. Not all people had a risk assessment to ensure that this type of equipment was suitable and did not pose additional risks to the person. We brought this to the attention of the provider during the inspection. We were told that the issue had been resolved. However, we checked a person’s bed rails and found that they were in the same unsafe condition as they were when we first identified the issue.
People’s nutritional needs were not always effectively met. Assessments of people’s risk of malnutrition were not completed properly and plans to monitor people’s weight loss were not followed. One person was placed at risk of choking as there were conflicting directions as to the consistency of their food and drink.
Care was not always assessed, planned or delivered to be responsive to people’s needs. For example, a person’s epilepsy care plan did not contain sufficient information to guide staff in the action to take in the event the person experienced an epileptic seizure. A person assessed as requiring a pressure-relieving mattress to reduce the risk of them developing a pressure ulcer did not have this type of equipment on their bed which placed them at risk. One person had asked staff to assist them to use the toilet. Over 40 minutes later the person remained in the lounge and had not been assisted to the toilet. We informed the manager that this person had not been assisted to ensure their needs were met.
People’s medicines were not always managed safely. Staff administered two people’s medicines at the same time which increased the risk of error. Medicine trollies were not always secured to the wall when not in use and medicine was left unattended. Controlled Drugs (CD) were not managed appropriately as the medicines recorded in the CD register did not correspond with the medicines held in the CD cupboard. The manager told us that this was a recording error as the CDs had been returned to the pharmacy but the register had not been updated.
The provider had not made suitable arrangements to respond to actual or alleged abuse. The manager was not aware of the local safeguarding and a complaint alleging neglect was not reported to the local authority as is required. Staff were aware of what constitutes abuse, the signs and how to report abuse. Staff were aware of the concept of whistle-blowing and outside organisations they could contact if they had concerns, such as the local authority.
People were not protected from the risks of unlawful deprivation of liberty as the provider had not made appropriate arrangements. People’s care records indicated that they were under continuous supervision and control and were not free to leave the home. The manager told us they were aware of a change in the law in relation to the Deprivation of Liberty Safeguards (DoLS). However, they had not taken action to assess whether or not the change in the law would require them to seek DoLS authorisations for people living at the home.
Not all staff had received the training necessary to carry out their roles. in subjects such as the Mental Capacity Act and moving and handling. Staff had not received formal supervision as identified in the provider’s policy and had not had appraisals. Staff told us they felt they had enough training and received feedback as to their performance.
People’s privacy and dignity was not always respected. Staff assisted one person to change position using a hoist in an undignified manner. Staff carried walkie-talkies and it was audible discussion around peoples personal care. However, doors to people’s bedrooms were kept closed during personal care and people’s relatives told us that staff were polite and helpful.
During our observations people had brief or no contact with staff . The television and radio were both on and call bells were audible within the lounge area. The mixture of noises may have had an adverse effect on people’s well-being.
People’s care records did not always contain accurate or up-to-date information and there was a risk that staff would not be responsive to their needs. For example, one person’s care records indicated two different pieces of equipment that the person should use to change position. It was not clear which piece of equipment the person should use. The manager told us records were not up-to-date.
The provider had not made statutory notifications to the commission. A statutory notification is information about important events which the service is required to send us by law. The manager told us that they were not aware that notifications were required for this type of event.
The provider did not have an effective system to monitor the quality of the service or identify, assess and manage risks. The manager told us that audits of practice had not been undertaken properly or consistently. Audit reports stated that practice was safe in the management of medicines which was contrary to our findings.
The provider had a complaints procedure which staff were aware of. People told us they felt able to raise concerns and were confident that the provider would respond to them. However, the complaints procedure was not displayed to ensure people had access to this.
There were sufficient numbers of staff to keep people safe but not always meet their needs in a timely manner. People and staff had mixed views as to whether or not there were enough staff. One person told us that there was sometimes a long wait for staff to answer their call bell. Staff reported they could be rushed and did not have enough time to spend with people. People waited an excessive amount of time to be supported to transfer from their wheelchairs to lounge chairs following their lunch.
People accessed healthcare professionals when they required. People’s care records showed that they had received treatment from a variety of healthcare professionals. People told us they saw the doctor when they needed to. Two visiting community nurses told us that the staff at the home made appropriate referrals and followed their advice.
People felt involved in making decisions about their care. One person told us they could get up and go to bed at times convenient to them. Relatives told us they felt staff were informative and helpful and involved them in developing their relative’s care plan.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.
Focussed inspection of 26 November 2014
After our inspection on 11 and 12 August 2014 the provider was served a warning notice because they had not taken proper steps to ensure that people were protected against the risks of inappropriate or unsafe care because care had not been assessed, planned or delivered to meet people's needs or ensure their welfare. This required the service to be compliant by 29 September 2014. We carried out this unannounced focussed inspection to check that the breach of the regulations had been addressed. We found that the provider had taken appropriate action and had complied with the warning notice.
People received support from staff who were kind and attentive. People were kept safe and protected from risks wherever possible.
People's needs were assessed and plans were in place to ensure that their care needs were met. We saw that people's privacy and dignity were promoted.