Sowerby House

Updated 28 September 2022

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. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team 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.

Service and service type

Sowerby House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Sowerby House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was not a registered manager in post. The provider had successfully recruited a manager on, 8 June 2022, who was currently going through the registration process.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We spoke with the manager, the operations manager and ten people who lived at the service as part of the inspection. We reviewed a range of records. This included six peoples care records and multiple medication records. We looked at three staff files in relation to recruitment and supervisions.

After the inspection

We reviewed a variety of records relating to the management of the service and to spoke with five relatives and five staff members. We continued to seek clarification from the provider to validate evidence found. We looked at policies and procedures and quality assurance records.

Updated 28 September 2022

About the service

Sowerby House is a residential care home providing accommodation to people who require nursing or personal care to up to 51 people in one adapted building, across two floors. The service provides support to older people and young adults who may be living with dementia or physical disabilities. At the time of our inspection there were 32 people using the service.

People’s experience of using this service and what we found

People were not safe. The risks to people had not always been assessed and more detail was needed in the care plans to ensure staff knew how to manage and mitigate the risks to them.

There was insufficient staff to meet people’s needs. People and staff reported delays in responding to call bells and people’s care preferences were either not recorded or followed by staff. Staff did not always benefit from training and constructive supervision to support them in their role.

Effective infection, prevention and control measures were not in place and the service was unclean, putting people at risk of infection. Cleaning tasks were not completed in the expected time frame and domestic staff were under pressure due to gaps in recruitment.

People were supported to have their medication when needed, however the management and storage of some medications was not safe and put people at risk.

Appropriate safeguarding processes had not been followed which meant people were at risk of being deprived of their liberty without lawful authority. We asked the provider to take action to rectify this without delay.

Quality and safety checks were in place however, these failed to highlight all the shortfalls found on inspection. Where audits had indicated areas to improve, action was not taken in a timely manner.

People could take part in activities however; these were tailored more to those people in the communal areas which left the people who were cared for in their rooms with little stimulation and at risk of isolation. We made a recommendation about this.

Complaints were recorded and investigated by the management team. However, it was unclear if lessons had been learnt and improvements made when shortfalls were found. We have made a recommendation about this.

People were not supported to have maximum choice and control of their lives and staff did not support them in their best interests; the policies in the service promoted a person-centred approach but staff practice contradicted this.

Staff were seen to be caring and wanting to do what was best for people however, limitations on their time meant people were not always in receipt of effective care, based on their preferences.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 06 August 2021 and this is the first inspection.

The last rating for the service under the previous provider was requires improvement, published on 16 April 2021.

The service remains rated as requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service and in part due to concerns received about the standards of care people received. A decision was made for us to inspect and examine those risks. We also needed to provide a rating under the new provider.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

As a result of the inspection the manager developed an action plan in relation to the concerns raised and plans to review their practice to help mitigate the risk to people.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the safety of the service, staffing levels and staff’s ability to provide person centred care. We have also identified a breach in relation to the governance and oversite of the service and the providers ability to ensure service users are protected from abuse and improper treatment.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.