Archived: Glen Rose

Updated 15 May 2019

The inspection:

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

The inspection was prompted in part by concerns we had received about the management of the home and so we focussed on the key questions, Safe and Well led.

Inspection team:

The inspection consisted of two inspectors 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. This person had personal experience of caring for people with dementia.

Service and service type:

Glen Rose is a ‘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 service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection:

The inspection was unannounced.

What we did:

Before the inspection we reviewed information, we had received about the service since the last inspection. This included details about incidents the provider must notify us about, for example, injuries that occur in the service and any allegations of abuse. We also requested feedback from two health care professionals.

Some people using the service were not able to verbally express their views about the service. Therefore, we spent time observing interactions between staff and people within the communal areas of the home. We spoke to four people, five relatives/friends, 11 members of staff, the registered manager, general manager and nominated individual. We looked at the care records for seven people and the medicines records for nine people. We also looked at four staff recruitment records; five agency staff records and records relating to the quality and management of the service.

Following the inspection, we requested further information regarding agency workers training, policies and some measures of support for people. We didn't receive everything we asked for.

Updated 15 May 2019

About the service: Glen Rose is a residential care home that was providing personal and nursing care to 15 older people at the time of the inspection. The majority of people living in the home were living with dementia as well as physical health needs. Early into the inspection, the inspection team were informed by members of the senior management team for the provider, that the provider had made the decision to close the care provision at Glen Rose and that they would be working with the Local authority to ensure a 28 day closure programme was arranged.

People’s experience of using this service:

• At this inspection we found the service was not well led. It lacked a person-centred focus, managers lacked a clear understanding of regulatory requirements and governance systems were not operated effectively so concerns were not always identified and acted upon. This meant people were not always safe.

• We found people were not always protected against the risk of abuse or avoidable harm because the registered persons had not ensured concerns were always reported to the local authority and had failed to complete prompt and through investigations into unexplained injuries.

• People were put at risk of receiving unsafe care and treatment because risks associated with people’s care were either not assessed, lacked effective plans to reduce risks and when they were in place staff failed to always follow these.

• People were put at risk of receiving unsafe care and treatment because a high number of agency staff were being used and the registered persons had failed to ensure they had received sufficient information to be confident they were safe and trained sufficiently to work with adults at risk. In addition, registered persons had failed to ensure all agency staff had access to information they needed to understand and support people living in the home. At times we could not be confident that sufficiently skilled staff were available. We have made a recommendation about the assessment of staffing levels and skill mix, as well as the deployment of staff.

• The service met the characteristics of inadequate in the areas we looked at; more information is in the full report.

Rating at last inspection:

This was the first inspection of the service since the provider changed in January 2019.

Why we inspected:

In January 2019 the provider of this service changed, however no changes were made in terms of the individuals running and managing the organisation. The Commission had been made aware before the inspection of a number of concerns about the safety and quality of this service.

Follow up: Following the inspection we shared our concerns with the local authority. The provider also submitted a notification to advise us that they planned to close the home as of 12 April 2019 and were working with the local authority to ensure people moved safely to alternative and appropriate accommodation. We continued to liaise with the provider and local authority throughout this process.

Enforcement: We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. 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.

Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.