Background to this inspection
Updated
31 March 2020
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 Care Act 2014.
Inspection team
The inspection was carried out by two inspectors, one assistant inspector and one 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. Their area of expertise was 'older people'.
Notice of inspection
This inspection was unannounced.
What we did before inspection
We reviewed information we had received about the service since the last inspection. We used information we had received through our ongoing monitoring of the service and feedback we received from the local authority. Prior to our inspection we were informed by the local authority they had placed a voluntary embargo on any new admissions to the home, this was due to the local authority having concerns about the home. We used information the registered provider sent us in the Provider Information Return. This is information registered providers are required to send us with key information about their service, what they do well and improvements they plan to make. This information helps support our inspections.
During the inspection
We spoke with 12 people and one person’s relatives about their experience of the care provided. We spoke with eight members of staff including, the home manager, the deputy manager, one nurse, three care workers, the activities co-ordinator and the cook. We also spoke with two members of the external nursing team and a manager from Trafford Borough Council. 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.
We reviewed records relating to the care people were receiving and the management of the service. This included, the medicine systems, six care plans, training and supervision records, audits, records of servicing and maintenance and a sample of policies and procedures.
Updated
31 March 2020
About the service
Serendipity Home is a care home providing personal and nursing care to a maximum of 45 older people some of whom may be living with dementia and/or physical disability. At the time of the inspection the service was supporting 30 people.
People’s experience of using this service and what we found
People at risk of harm were not always adequately protected. Risk management was poor, with risks not always being assessed or reviewed. Incidents were not always being recorded or reported
appropriately. We made an urgent referral to the Greater Manchester Fire and Rescue Service (GMFRS) as we were concerned the homes fire risk assessment highlighted a number of outstanding works. We are currently liaising with GMFRS and the local authority to ensure these works are completed.
People who developed pressure ulcers or whose health needs changed were not always referred to health care professionals in a timely way. Staff were not always responsive to people's changing needs to ensure that the care and support they provided to people was personalised.
We found there were continuing, multiple and serious shortfalls significantly increasing the risk people would not receive safe care and treatment. Safeguarding incidents were not reported or investigated appropriately. The manager and staff did not recognise or respond to safeguarding incidents or follow established local procedures for reporting and investigating them.
The service was not well-led. There was insufficient risk management and quality monitoring. Statutory notifications were not always submitted when required. The registered provider and manager lacked an understanding around their regulatory requirements.
People did not always have access to enough staff to meet their care and support needs. People, their relatives and staff told us on many occasions that there was not enough staff to support people safely.
People living with dementia, did not always receive person centred care. There was a lack of meaningful and stimulating interactions with staff to occupy people's time.
The environment needed investment. We found areas within the home were tired and required decoration. We have also made a recommendation the provider reviews dementia friendly environments and consults current guidance, as we found aspects of the home lighting and patterned carpets did not support a dementia friendly environment.
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. We have made a recommendation about capacity assessments and best interest decisions.
People's medicines were managed safely, and the home had greatly benefitted from Trafford Council’s medicines optimisation team with improvements to the medicines systems.
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 Requires Improvement (published 27 February 2019) with breaches in regulations 12 (safe care and treatment) and 17 (good governance). We requested that an action plan needed to be completed, however this was not done by the provider. At this inspection improvement had not been made and the provider was still in breach of these and new regulations.
Why we inspected
This was a planned inspection based on the previous rating.
Enforcement
We have identified breaches in relation to person-centred care, safe care and treatment, dignity and respect, safeguarding service users from abuse and improper treatment, good governance, staffing 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.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Special Measures
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 of 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.