22 March 2016
During a routine inspection
We contacted the Local Authority who continued to monitor the service and who put a suspension in place which meant the service could not admit any new service users until the provider could demonstrate significant improvements. Following our inspection on the 6 January 2016 we served three warning notices around the most significant breaches which included Regulation 12: Safe care and Treatment, Regulation 9, Person Centred care and a warning notice under section 33 of the Health and Social Care Act 2008 for the failure to have a registered manager. There had not been a registered manager since May 2015.
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.
The warning notices served gave the provider additional opportunity to address our escalating concerns and they were given twenty eight days to comply with the Warning notices. We also met with the provider and other trustees to explain our concerns and our enforcement powers in light of escalating concerns.
We inspected the service again on the 22 March 2016. The purpose of this inspection was to follow up on the progress made towards meeting the warning notices as the date for compliance was set for the end of February 2016. However due to other concerns raised about the service we decided to carry out a full comprehensive inspection to satisfy ourselves that people were safe.
We found slow progress was being made but not in a sufficiently timely way. We did not consider everyone using the service was having their needs met or that risks to people’s safety were being addressed. The provider had not made sufficient progress to be meeting the regulations at this time.
During this inspection we identified continued breaches with regulations as cited in the previous report following the inspection on the 6 January 2016.
Care plans had been updated and there was a daily record of people’s needs. However this information was not sufficiently robust. Changes in the staff team meant that not all staff were familiar with people’s needs and did not always refer to the care plans to help them know what support people needed. The monitoring of people needs and reporting on changes was sporadic. Staff were not consistently filling in records or giving enough information to enable us to make a judgement about how well people’s needs were being met. Throughout our observations during the day we saw staff were pushed for time and people using the service were often left unstimulated for long periods of time with very little to occupy them. The care was task focussed and risks to people were not fully mitigated as some people would be unable to call for help and staff were not often present in communal areas.
Risks to people’s health and safety were not fully mitigated and risk assessments did not take into account all the risks. Where actions to keep people safe had been identified. These were not always followed through which meant risks were not clearly managed.
Staffing levels had increased but some staff were new and not yet familiar with the daily routines. Staff were not sufficiently deployed throughout the day and when the activities coordinator was not on duty staff did not offer people sufficient, meaningful occupation. The provider had introduced a dependency tool which is a means of assessing how much care and support people needed and how many staff they needed to safely provide the care. However we could not be assured of the accuracy of the tool as our observations gave us concern about how the provider was meeting people’s needs. There was also a genuine difficulty in fulfilling the quota of staff the service said it needed. On the day of our inspection staff rang in sick, did not turn up for duty and there was concern about the weekend cover. This was putting additional pressure of existing staff and meant that some staff were unable to fulfil their roles properly .For example the manager and administrator were working on the floor supporting care staff rather than carrying out their own duties. Some staff had reported that some senior staff did not always support them as required. This meant we could not be assured the service was always sufficiently staffed and well managed.
We looked at medication to assure ourselves it was being administered safety and found senior staff were knowledgeable about medication and people received their medicines safely. We identified a couple of concerns about people not always taking their prescribed medicines and people being administered medicines as directed all the time. So for example where people were prescribed pain killers up to four times a day staff were administering these up to the maximum amount without always establishing if people needed them.
We looked at staffing in relation to training, recruitment and supervision. Staff training was being undertaken for all staff but we did not look at the quality or effectiveness of this training. We were concerned that staff did not necessarily have the skills or competencies to meet the specific needs of people using the service. For example staff had not had dementia training or training around specific medical conditions.
Staff recruitment was not always sufficiently robust and this needed to improve and the provider was not always following their own recruitment processes.
The care observed was appropriate to people’s needs but little attention was given to people’s emotional and psychological well- being. Care was not centred around the needs of individuals and not all staff were familiar enough with people’s needs. Care plans gave insufficient information about people’s life stories which might enable care staff to understand people’s needs further. There was a plan of activities but some people were benefiting from this more than others and people’s experiences varied with a number of people feeling frustrated and unstimulated.
Some progress has been identified but is slow. There were some systems in place to check the quality and effectiveness of the service delivery but poor evidence of how people using the service were being consulted. We identified concerns at our inspection which had not been identified by the service. Roles and responsibilities were not clearly defined and staff were unclear about who they were directly accountable for.
Records were poor and it was difficult to find the information we needed or to know what the persons’ current needs were and how changes had been addressed.