Archived: Seahorses Nursing Home

Updated 1 September 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 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 inspection took place on 3 and 5 July 2018 and was unannounced. The inspection team consisted of one inspector and a specialist advisor in nursing care.

As part of our inspection planning we reviewed all the information we held about the service. This included previous inspection reports and any notifications sent to us by the service including safeguarding incidents or serious injuries. This helped us determine if there were any particular areas to look at during the inspection. We contacted the local authority safeguarding and quality team prior to the inspection.

We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

At the time of inspection there were eight people living at the service. To help us assess how people's care needs were being met, we reviewed five care records and other information, including risk assessments and medicines records. We reviewed three staff recruitment files, maintenance files and a selection of records which monitored the safety and quality of the service.

During the inspection we spoke with three people who lived at the service, one relative, two health professionals, the registered manager and provider, and two members of care staff.

Updated 1 September 2018

This inspection took place on 3 and 5 July 2018 and was unannounced. The last inspection was in April 2017, where we found four breaches of regulations relating to recruitment, person centred care, staffing, and governance of the service. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe and well-led to at least good.

At this inspection in July 2018, we found the provider had failed to follow their action plan. We identified significant shortfalls in the quality of the care people were receiving and 10 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found two breaches of the Care Quality Commission (Registration) Regulations 2009.

Seahorses nursing home 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. Seahorses nursing home accommodates up to eight people in one adapted building. The majority of people in the service were living with Huntington’s disease. At the time of this inspection there were eight people living in the service.

There was a registered manager in post. 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.

The provider did not have the financial resources needed to provide and sustain the service to the required standards. They had not informed us about their current financial position which was directly impacting on the care people were receiving.

A system was not in place to ensure there were sufficient numbers of staff on duty to support people and meet their individual care needs. There were not sufficient numbers of skilled, trained and experienced staff to meet people's needs effectively at all times. The provider had reduced staffing levels since the last inspection in April 2017, and this had directly impacted on the care people received placing them at extreme risk of harm.

Governance systems were not operated effectively in order for them to provide an accurate overview of the service. Proper monitoring was not in place to review, identify shortfalls and inform an ongoing plan for improvement. The provider's systems had failed to identify the issues we found during our inspection. Audit and monitoring systems had either not been sustained or were ineffective to ensure that the quality of care was consistently assessed, monitored and improved.

Monitoring systems were not effective to demonstrate accidents and incidents were appropriately analysed to identify hazards, trends or themes, to mitigate the risks of further accidents and incidents.

Thorough risk assessments were not carried out routinely to identify and mitigate risks in relation to people's care and support needs. Risks affecting people had not been reviewed since April 2018.

The culture within the home did not promote a holistic approach to people's care to ensure their physical, mental and emotional needs were being met. Staff spoke abruptly when interacting with people, and did not provide emotional reassurance when people became distressed.

The service was not following the principles of the Mental Capacity Act 2005. Minimal improvement had been made to ensure the way that people’s care was delivered did not restrict their freedom more than necessary.

The service did not ensure that safeguarding procedures were followed when there were two significant thefts from people using the service. Systems were not improved to reduce the risk of recurrence.

The provider had not put in place all that was reasonably practicable to maintain the building upkeep, to ensure the premises were safe to use for their intended purpose. The provider had not replaced worn and damaged furniture as required to keep the premises and equipment appropriately maintained.

People were not protected from the risk of infections due to staff not adhering to safe infection control procedures. Many areas of the service were unclean, and equipment such as bed rail coverings and specialist wheelchairs could not be cleaned effectively due to the plastic coverings becoming worn and split.

Systems used to ensure the water system was safe from legionella bacteria were not robust.

People's medicines were not managed or administered safely. People did not always receive their medicines as prescribed. This included prescribed creams.

Care plans for people who had complex health care needs had not been developed to offer guidance to staff on how to maximise people’s health and keep them safe.

People did not receive any social activity or stimulation; staff did not have time to deliver this in addition to their caring duties. The provider had not followed our previous recommendation in order to improve this area of people’s care.

Following the inspection we urgently raised our concerns with the clinical commissioning group and local authority who responded swiftly to meet with the provider and discuss the concerns. People living in the service were subsequently moved to local nursing homes with the support of the local authority and this service is no longer operating.