Addison Court

Updated 16 February 2024

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.

Inspection team

The inspection team consisted of 3 inspectors, a medicines inspector 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

Addison Court 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. Addison Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post. The registered manager was absent during the inspection.

Notice of inspection

The inspection was unannounced. Our first visit was out of hours so we could assess the night-time staffing situation.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. 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 15 people who lived at the service and 7 relatives. We spoke with 16 staff; the director of care, the head of compliance, the compliance manager, the operations manager, 1 nurse, 2 senior care workers, care workers, housekeeping staff, maintenance staff and activities coordinators. We reviewed a range of documents relating to the safety and management of the home. This included 10 medicine administration records and associated care plans, a further 6 care plans and 5 staff recruitment files. We also reviewed medicine audits completed by the service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 16 February 2024

About the service

Addison Court is a residential care home providing personal and nursing care to up to 70 people. The service provides support to older people, some of whom were living with dementia. At the time of our inspection there were 62 people using the service.

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

The provider did not always act robustly to investigate and support people raising concerns about their care. The safeguarding log did not accurately record action taken or lessons learnt from reviewing safeguarding concerns. The provider did not always ensure risks were assessed and mitigated. Although sufficient numbers of staff were on duty. On the days of the inspection the use of agency staff had increased. These staff told us that they did not know people’s needs well enough. The provider did not recruit new staff in line with the regulations and their own procedures. People and relatives gave mixed feedback about staffing levels.

The provider’s quality monitoring systems had not been used effectively to ensure trends were identified, fully investigated and lessons learnt following incidents, accidents and falls. Records did not demonstrate complaints had been fully investigated. Duty of candour requirements were not always followed and there had been a lack of management oversight at the service.

The provider's staffing dependency tool did not account for all factors which impacted on staffing levels. We have made a recommendation about this.

Improvements were required to ensure people had a positive mealtime experience. Records did not always demonstrate how staff supported people to achieve their target fluid levels. We have made a recommendation about this.

Care reviews, involving relatives where appropriate, had not been carried out as planned. Some care plans were not up to date or contained conflicting information.

Staff spoke positively about the people they supported. They told us the care at the home was good enough for their family or friends. Three staff had been nominated for an “Angel award” in recognition for their outstanding contributions to the local community.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Checks were completed to maintain a safe environment. Staff knew about the whistle blowing procedure and were confident to raise concerns. Staff followed good infection prevention and control (IPC) practices. People were supported to access healthcare services in line with their particular needs.

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

Rating at last inspection

The last rating for this service was good (published 27 October 2022).

Why we inspected

This inspection was prompted by a review of the information we held about this service. The inspection was also prompted in part due to concerns received about staffing levels, moving and assisting, recruitment and management oversight. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report. Please see the safe, effective, caring, responsive and well-led sections of this full report.

Enforcement and recommendations

We have identified breaches in relation to person-centred care, safe care and treatment, safeguarding, complaints, good governance, fit and proper persons employed and duty of candour.

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.

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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.