Archived: Mu'Gbortima Care Services

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

We were alerted by the local commissioners of the service of concerns in relation to the safety and suitability of the premises, the planning and delivery of care, and staffing at the provider's care home. Due to these concerns, we brought forward our scheduled inspection of the provider's care home. During this inspection visit, we found numerous failings in the provider's systems to deliver safe and effective care. We also found serious concerns in regards to the safety and suitability of the premises. Due to the seriousness of the concerns identified, we also brought forward a scheduled inspection of the provider's care service registered to provide personal care to people in their own homes.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The home was unsuitable for purposes of providing nursing care to people with high dependency needs. There was no passenger lift or other safe way of assisting people to access the bedrooms and living areas situated on other floors. There was little space in the lounge and dining areas for people with mobility aids and adaptations to sit in a comfortable and safe way.

People receiving care at the home had not received an assessment of their needs before they started to use the service. They were also insufficient risk assessments and care plans in place to make sure people were cared for in a safe way. People receiving care in their own homes also had inadequate care planning information in place.

The provider did not have an effective recruitment system in place to ensure staff were of good character and had up to date professional registration. Staff working rotas did not show the accurate deployment of staff working at the home and in the community. This put people at risk of harm because the rotas did not provide a plan to show people were supported by sufficient numbers of suitably experienced and qualified staff. This meant there was a breach of the Health and Social Care Act regulations. We have taken Enforcement action against the provider.

Is the service effective?

The home did not provide a suitable environment for people's social needs. The lounge and dining areas were not big enough to be able to accommodate people with their mobility aids and adaptations. People were nursed in isolation in their bedrooms and were not given opportunities for their social interaction.

Some people receiving care in their own homes and their relatives told us that they were happy with the standard of care provided. One person said that staff provided care that prevented them from developing pressure ulceration. This included the daily checking of their skin and application of cream to keep their skin in a good condition. However, one person told us that they did not always receive their care in accordance with their plan of care. This was because their care plan stated that they needed a care visit late at night. The person told us that carers did not always visit to attend to their needs at this time. We also found that daily records maintained by the staff showed that they had not always attended to the person's needs at the correct time which meant the person was at risk of receiving unsafe care. This meant there was a breach of the Health and Social Care Act regulations. We have taken Enforcement action against the provider.

Is the service caring?

People were supported by kind and attentive staff. People living at the home looked well cared for and were comfortable within their environment. Staff referred to people by their preferred name and when possible involved them in decisions about their care and support.

However, we had serious concerns that the provider intended to nurse people in their bedrooms and we found no evidence that the provider had considered people's emotional wellbeing or their need for social interaction with other people as part of their care planning. This meant there was a breach of the Health and Social Care Act regulations. We have taken Enforcement action against the provider.

One relative of a person receiving care in their own home told us that staff were 'Very nice and helpful'. Another person said 'They are pretty good and are caring staff'. We observed that the provider had received a series of compliment letters and cards from relatives of people who had used the service. We saw that the letters and cards expressed 'thanks' to the staff for the care they had provided.

Is the service responsive?

One person receiving care at the home had risks associated with swallowing and required a special diet. The provider had not undertaken risk assessments to ensure risks relating to swallowing had been identified. We were concerned that the person had not always received a soft diet that met their nutritional needs.

One person receiving care in their own home told us that staff had responded to variety of their care needs. This included receiving the services of a 'night carer' who had been attentive of their needs and had made them comfortable throughout the night time. However, another person receiving care in their own home told us that the care staff did not always attend to their evening call. This meant they had to wait at least 13 hours before the carers came and attended to their needs in the morning time. They also told us that staff did not always care for them for the agreed length of time. This meant there was a breach of the Health and Social Care Act regulations. We have taken Enforcement action against the provider.

Is the service well-led?

The provider did not have a quality assurance system in place that enabled them to identify, assess, monitor and manage risks in the service. This led to serious failings in the care home and in the provider's domiciliary service. The provider did not have a system in place to obtain regular feedback about the quality of service from people who used the service.

There was no system in place to provide clinical leadership at the home. The provider told us that they were responsible for clinical leadership. However, they could not present evidence of their general nursing qualification with the Nursing and Midwifery council. This put people at risk because staff had no clinical leadership to provide care that met health and safety standards.

The provider had commissioned the support of a management consultant who was supporting them to manage the service. However, the provider did not understand the seriousness of the failings that were identified at the home and in the domiciliary service. The provider was asked to provide us with staffing rotas, a list of people who received personal care and information about staff employed by the service. Despite being given several opportunities to provide this information they failed to provide an accurate and consistent record of the information requested. This meant there was a serious risk that people would receive unsafe care and might be harmed. This meant there was a breach of the Health and Social Care Act regulations. We have taken Enforcement action against the provider.