About the service Sowerby House is a residential care home providing accommodation to people who require nursing or personal care to up to 51 people in one adapted building, across two floors. The service provides support to older people and young adults who may be living with dementia or physical disabilities. At the time of our inspection there were 32 people using the service.
People’s experience of using this service and what we found
People were not safe. The risks to people had not always been assessed and more detail was needed in the care plans to ensure staff knew how to manage and mitigate the risks to them.
There was insufficient staff to meet people’s needs. People and staff reported delays in responding to call bells and people’s care preferences were either not recorded or followed by staff. Staff did not always benefit from training and constructive supervision to support them in their role.
Effective infection, prevention and control measures were not in place and the service was unclean, putting people at risk of infection. Cleaning tasks were not completed in the expected time frame and domestic staff were under pressure due to gaps in recruitment.
People were supported to have their medication when needed, however the management and storage of some medications was not safe and put people at risk.
Appropriate safeguarding processes had not been followed which meant people were at risk of being deprived of their liberty without lawful authority. We asked the provider to take action to rectify this without delay.
Quality and safety checks were in place however, these failed to highlight all the shortfalls found on inspection. Where audits had indicated areas to improve, action was not taken in a timely manner.
People could take part in activities however; these were tailored more to those people in the communal areas which left the people who were cared for in their rooms with little stimulation and at risk of isolation. We made a recommendation about this.
Complaints were recorded and investigated by the management team. However, it was unclear if lessons had been learnt and improvements made when shortfalls were found. We have made a recommendation about this.
People were not supported to have maximum choice and control of their lives and staff did not support them in their best interests; the policies in the service promoted a person-centred approach but staff practice contradicted this.
Staff were seen to be caring and wanting to do what was best for people however, limitations on their time meant people were not always in receipt of effective care, based on their preferences.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 06 August 2021 and this is the first inspection.
The last rating for the service under the previous provider was requires improvement, published on 16 April 2021.
The service remains rated as requires improvement. This service has been rated requires improvement for the last two consecutive inspections.
Why we inspected
This inspection was prompted by a review of the information we held about this service and in part due to concerns received about the standards of care people received. A decision was made for us to inspect and examine those risks. We also needed to provide a rating under the new provider.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
As a result of the inspection the manager developed an action plan in relation to the concerns raised and plans to review their practice to help mitigate the risk to people.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to the safety of the service, staffing levels and staff’s ability to provide person centred care. We have also identified a breach in relation to the governance and oversite of the service and the providers ability to ensure service users are protected from abuse and improper treatment.
Please see the action we have told the provider to take at the end of this report.
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.