Archived: Overton House

Updated 14 November 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.

The inspection took place on 03 September 2018 and was unannounced. This meant the service did not know we would be visiting. We carried out a further announced visit on 04 September 2018 to complete the inspection.

During the course of the inspection, the inspection team comprised of three adult social care inspectors and an inspection manager from the Care Quality Commission.

Before the inspection the service had not completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. However, we reviewed information we held in the form of statutory notifications received from the service, including those related to safeguarding incidents and injuries. Ahead of the inspection we also liaised with the local authority.

During this inspection we spoke with five people who used the service. However, due to the nature of the service provided at Overton House, we also completed a 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.

We also spoke with seven members of staff including the provider, registered manager, deputy manager, senior carers, care assistants, the cook and one visiting professional. Throughout the period of our inspection visit no relatives or friends visited people who used the service.

We looked in detail at six care plans and associated documentation; four staff files including recruitment and selection records; training and development records; audit and quality assurance; policies and procedures and records relating to the safety of the building, premises and equipment.

Updated 14 November 2018

Please be advised Overton House has now closed.

The inspection took place on 03 September 2018 and was unannounced. This meant the service did not know we would be visiting. We carried out a further announced visit on 04 September 2018 to complete the inspection.

Overton House was 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.

Overton House was registered with CQC to accommodate a maximum of 19 people. At the time of this inspection 14 people were accommodated and two people were in hospital. The majority of people who used the service at Overton House were living with enduring mental health issues and were extremely vulnerable.

We last inspected Overton House in 2016 when the service was owned and operated by a different provider and at that time we rated the service ‘Good.’ However, in 2017 the business was sold to a new provider and in August 2017 Overton House was re-registered with CQC, as is the legal requirement.

At this inspection we found widespread systemic failures and multiple breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 concerning safe care and treatment, premises and equipment, staffing, the need for consent, dignity and respect and good governance. In the days immediately following our inspection visit, due to the seriousness of the issues we found, we informed the provider that we proposed to take urgent action to ensure the health, safety and well-being of people who used the service. We also informed Manchester Health and Care Commissioning (MHCC) of our intentions.

In response to the serious concerns raised by CQC, the provider informed us they had decided to close Overton House. On receipt of this information CQC liaised extensively with MHCC who took steps to ensure the immediate needs of people were being met. Two people who used the service were also identified as being out of area placements funded by Trafford Council, therefore Trafford local authority also provided additional support. By Monday 10 September 2018 all the residents had been found alternative accommodation.

Whilst the provider made a business decision to close Overton House, CQC has taken enforcement action to remove the providers registration in respect of the carrying on of a regulated activity at Overton House. Details of this are contained at the back of this report.

The service had a registered manager. 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.

On the first day of our inspection we conducted a tour of the premises at Overton House. The tour included the basement, communal areas and resident’s private bedrooms’. During the tour we found significant areas of concern relating to the prevention and control of infection and found systemic poor practice which placed residents at a serious risk of harm.

We found the outside space to the rear and side of Overton House to be exceptionally unsafe. The concreate floor was uneven and posed a serious falls risk, hazardous materials associated with building maintenance had been discarded, there were loose bricks and rubble present which posed a risk of injury and steep concrete steps leading down to the basement area posed a serious falls risks.

Throughout the premises we found window restrictors were non-compliant with Health and Safety Executive (HSE) guidance or were missing entirely. We also found that whilst a care call alarm system was situ there were no pull cords available that would assist a resident to raise an alarm when they found themselves in difficulty or in the event of an emergency.

We looked at induction and training staff received to ensure they were skilled and competent to fulfil their roles. We found that a programme of unsupported training was in place delivered solely via online E-learning. We found no assessments of competency had been completed which meant there was no assurance that staff were sufficiently skilled and competent to provide care safely.

We looked at the mealtime experience and found this to be poor. In the dining room no menus were displayed. We asked the cook about this and were shown an example of weekly menus that had been stored in a cupboard in the kitchen. However, upon further investigation, we found the actual produce and ingredients that were available on the premises was not reflective of the menus, including an insufficient quantity of available ingredients. This meant it was impossible the daily menus shown to us were reflective of current practice.

The majority of care staff were well intentioned but it was evident, through talking to staff and from our own observations, that management and staff had been become completely disengaged from the service and there was an apathy across all aspects of the home . This had a detrimental impact on the quality of care being provided at Overton House. At provider level, there was a distinct lack of care and compassion shown towards the people who used the service. As evidenced by the conditions in which people were living.

The systemic issues found during this inspection meant there was a disregard for the human rights of people who used the service and there was no consideration given to any aspect of equality and diversity and to those people who may be from diverse backgrounds.

In all the care records we reviewed, we found an unacceptable level of variation. Some people had comprehensive care plans reflecting their support needs, likes, dislikes and personal preferences, whilst others distinctly lacked meaningful information that would enable staff to provide a responsive, person-centred level of care.

People's social needs were not being met which exposed them to an unacceptable risk of social isolation. Throughout the inspection we did not observe any meaningful activities taking place and we found no evidence that the home had historically attempted to engage people in activities that were non-care related.

Since the new provider took over Overton House in August 2017, the home had not been well-led. Every aspect of the service had been allowed to deteriorate which meant fundamental standards of quality and safety could not be met.