Archived: Garden House

Updated 21 July 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 registered 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 10 and 11 April 2018 and was unannounced on the first day. The inspection team consisted of a pharmacy inspector, two adult social care inspectors and an inspection manager.

Before the inspection we reviewed information available to us about this service. We had not requested a 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. We reviewed safeguarding information and statutory notifications sent by the provider. A notification is information about important events which the provider is required to tell us by law, like a death or a serious injury. We contacted the local authority safeguarding and quality performance teams to obtain their views about the service.

During the inspection, we observed how staff interacted with people who used the service throughout the day and at mealtimes. We spoke with eight people who used the service and two people who were visiting their relatives or friends. We spoke with the director, regional manager, acting manager, deputy manager, three senior care workers, three care workers, the cook, two domestic staff, the maintenance person and six visiting healthcare professionals.

We looked at eight care files and at other important documentation relating to people who used the service. We looked at how the provider managed people’s medicines and we checked records to ensure the provider was compliant with the Mental Capacity Act 2005.

We looked at a selection of documentation relating to the management and running of the service. These included staff recruitment files, training records, the staff rota, minutes of meetings with staff and people who used the service, quality assurance audits, complaints management and maintenance of equipment records. We completed a tour of the environment.

Updated 21 July 2018

This inspection took place on 10 and 11 April and was unannounced on the first day.

Garden House is registered to provide residential care for up to 40 older people. Accommodation is provided over two floors with both stairs and lift access to the first floor. An area of the service, ‘The Devonshire Suite’ provides support for up to 12 people living with dementia. The home is situated in Humberston, a suburb to the south of Grimsby.

Garden House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of this inspection 17 people were using the service.

At the last inspection on 17 and 21 November 2017, we rated the service as ‘Requires Improvement’ and we asked the provider to take action to make improvements in relation to person centred care, safe care and treatment, consent and good governance. Following the last inspection, we received an action plan and we met with the provider to discuss what they would do and by when to improve the key questions Safe, Effective, Responsive and Well-Led to at least good.

After receiving a number of safeguarding alerts about the home and information of concern from North East Lincolnshire Clinical Commissioning Group following their recent monitoring visits, we undertook this inspection. We found people were still not provided with safe care. Management of the service was disorganised and chaotic and there continued to be insufficient governance to mitigate the risks to people's health, welfare and safety. We found multiple concerns and are considering our regulatory response. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Immediately following our inspection, we formally notified the provider of our escalating and significant concerns. We asked the provider to tell us what urgent actions they would take with immediate effect to mitigate the risks we identified at this inspection. For example, in relation to the risks of poor staffing levels, the mismanagement of people's medicines and the unsafe moving and handling practises we had observed. We received a response with their improvement action plan on the 18 April 2018; this was not within the timescale requested.

There was no registered manager at the service. The registered manager had resigned and left the service in November 2017. A new manager had been appointed to the service in January 2018 and had resigned and left the service eighteen days before the inspection. A registered manager is a person who has registered with the CQC 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.

There was a lack of managerial oversight at all levels. There were shortfalls in how the service was managed overall and how care staff were overseen and supported when carrying out their roles. The office and recording systems were disorganised and some confidential information was not being stored securely. The provider had failed to ensure all statutory notifications of events and changes in the service had been submitted to the CQC.

We were told by staff and relatives and we saw evidence that there was a continued high turnover of staff, which was a concern. Appropriate recruitment procedures were not in place to ensure staff employed to work at the home were safe working with vulnerable people.

People were not always protected against the risks associated with the unsafe use and management of medicines. Some people had not received their medicines as prescribed due to errors in administration and non-application of creams.

There was a lack of robust risk assessment and management; people did not always receive safe care and support. Management oversight failed to ensure staff always followed policies and procedures, outcomes from risk assessment or sought and followed guidance from other health professionals.

There were concerns with the management of infection prevention and control due to the strong mal-odour present in one person’s room, the risk of cross contamination due to the build-up of laundry and staff’s inconsistent use of personal protective equipment and standards of hand hygiene.

There were not enough staff deployed to meet people’s needs. Staff rotas showed the levels of care staff frequently fell below the levels the regional manager told us were in place. We found staff were kind in their approach with people. However, most of the interactions were only brief as they were busy meeting people's personal care needs. At times people had to wait for assistance and staff were not always present in communal areas to ensure people's safety.

Training and induction of staff was not sufficient to ensure staff had the competencies and skills to meet the needs of people who used the service. Supervisions were not taking place regularly, which meant staff were not always appropriately supported in their role.

We found there was an inconsistent application of mental capacity legislation. Some people had assessments to determine their capacity to consent to specific restrictions such as bed rails, but others did not. Documentation showed best interest decision-making had not been completed appropriately. There were four people whom we felt should have been assessed to see if they met the criteria for a deprivation of liberty safeguard; they were living with dementia, resided in the Devonshire Suite and staff said these people wouldn’t be able to leave the home freely, as it would not be deemed safe for them.

Opportunities for people to be supported to lead meaningful lives and to participate in social activities of their choice and ability, particularly for people living with dementia were very limited.

People told us the staff were kind and caring, although they said some staff were better than others. Our observations identified people’s dignity was not always preserved.

Staff did not have up to date information about people’s individual needs which meant important person-centred care could be missed. There were gaps in some people's monitoring records for their food and fluid intake, weights, repositioning, bathing and bowel movements. Not everyone who used the service had a care plan and there were gaps in care planning for other people. Also care plans were not always updated when people’s needs changed and advice from health professionals was not transferred to the care plans.

People and their relatives told us that if they had any concerns they would discuss these with the management team or staff on duty. We saw a complaint had been received recently and managed in line with the provider’s procedures, however the senior management were not aware of the concerns and the complaints file and records were unavailable to evidence all complaints received and the actions taken to resolve these.

Staff knew how to recognise and respond to abuse although one member of staff was not aware of the external agencies they could contact. The service notified us of safeguarding incidents. There were a number of safeguarding concerns raised in recent weeks being investigated by the local authority safeguarding team.

The breakfast meal experience for some people on the first day of the inspection was poor, due to the length of time waiting for their meal. We saw meals were nicely presented and menus provided choice and alternatives. Staff supported people to eat their meals in an appropriate way and at a suitable pace for them. People told us they liked the meals provided to them.

The culture within the service did not promote a holistic approach to people's care to ensure their physical, mental and emotional needs were being met. Robust audit and monitoring systems were not in place to ensure that the quality of care was consistently assessed, monitored and improved. Quality assurance systems had failed to drive improvements from the last inspection or identify the majority of concerns we found during this inspection.

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 in