Archived: Northgate House (Norwich)

This service has a history of non-compliance with continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Seven inspections of this service had taken place since December 2014, three of these inspections with an overall rating of ‘Inadequate’ and four rated ‘Requires Improvement’.

This unannounced inspection took place on 10 September 2018. At this inspection, we found that there were four continued breaches relating to safe care and treatment, staffing, mental capacity and governance. There was one further breach of a regulation relating to safeguarding people.

We took enforcement action following an inspection of the service on 19 April 2017 where the service was given an overall rating of ‘Requires Improvement’ as we found the registered provider had continued to be in breach of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We placed conditions on the registered provider's registration to submit monthly reports to us setting out how they would assess, monitor and where required, take action to improve the quality and safety of the care and support provided to people living at Northgate House.

At the last inspection carried out on 7 March 2018, we found that there were continued serious concerns in relation to the quality and safety monitoring of the service. There was a continued failure to ensure people were protected from the risks associated with improper operation and management of the service including the premises. The service was in breach of seven regulations, which were Regulations 9, 11, 12, 14, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not provided with safe care. Oversight and management of the service was chaotic and disorganised. There continued to be insufficient governance arrangements in the service and therefore was still not effective in mitigating the risks to people's health, welfare and safety.

Following our comprehensive inspection on 7 March 2018, we formally notified the provider of our escalating and significant concerns. We asked the provider to inform us immediately of the urgent actions they would take with immediate effect to protect people and raise standards. We received a response to the urgent action letter on 12 March 2018, followed by an action plan addressing the concerns on 13 March 2018. This contained a basic action plan. We placed conditions on the provider’s registration to restrict admissions to the service. In response to our findings we notified the local safeguarding authority. Since our last inspection, the local authority has supported people who they commissioned care for to move to other locations.

At this unannounced inspection on 10 September 2018, we continued to have major concerns regarding the lack of action taken by the provider to ensure a safe service was provided. There was a continued lack of effective leadership and we found the provider continued not to have effective systems in place to provide safe, good quality care. There were three continued breaches and one further breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which we found, relating to safeguarding people. In addition, there was a breach of Regulation 18 of CQC Registration Regulations 2009.

The service continued to operate without a registered manager in post, and there had not been a registered manager for two years. 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 operations manager was currently acting as home manager and had submitted an application to register with CQC as the home manager. This application remains pending with CQC. For the purpose of the report we have referred to this person as the ‘manager’ throughout. There was a new deputy manager, who was not working on the day we inspected.

Risks to people’s safety and wellbeing had not always been identified and those that had been identified were not always mitigated. There remained concerns around medicines administration with no records around people’s prescribed topical creams and no guidance provided for staff for the administration of PRN (as required) medicines. Other medicines were given as prescribed.

Recent visits from environmental health inspectors and external auditors such as fire safety experts and a health and safety management auditor highlighted a number of areas where action was required by the provider to improve the safety of the environment and protect people from the risk of harm. Whilst the manager told us they had rectified these shortfalls, we found this was not always the case.

Staff had some knowledge of safeguarding from training, however people were not always properly safeguarded from the risk of abuse.

Accurate records of staffing available to meet people’s needs were not maintained. We were unable to ascertain exactly what hours staff had worked and when because the staffing was not accurately reflected in the rota. It was not clear from records maintained that all staff responsible for delivering personal care and support with mobilising people safely were competent in their roles. Staff received some training relevant to their role, however there was not always evidence of sufficient training for all staff delivering personal care. It was unclear whether there was consistent staffing at night to meet people’s welfare and safety needs.

The manager lacked understanding in their roles and responsibilities in relation to the Mental Capacity Act 2005. Best interests’ decisions were not always made when they were needed, and there remained a lack of understanding around consent. It was not clear how assessments of people’s capacity to consent to care were made.

Accurate, contemporaneous records of people’s care were not always kept because records did not reflect actual care delivered.

There continued to be poor leadership with a lack of effective oversight and governance of the service. The manager presented in a manner that lacked openness and transparency in carrying out the regulated activity. Health and safety checks were lacking and action had not been taken when external auditors had identified areas of risk to people’s safety.

There continued to be a high turnover of staff which did not provide continuity of care for people who used the service. There had been a further change of two managers since our last inspection. There were recruitment checks carried out to ensure that staff were suitable for the work they were employed to perform. However, the manager did not always maintain and record an oversight of staffs’ competency to ensure that staff remained suitably qualified to care for people in a safe way.

Care plans contained information about people’s hobbies, interests and social history. However, there was mixed feedback as to regularity of activities and the quality of support provided.

Relatives told us they could approach staff with any concerns, but they were not always resolved quickly. The provider had received some compliments.

There was a choice of meals available and people received enough to eat and drink. Staff supported people to access healthcare professionals and appointments.

On 13 March 2018, CQC used its urgent powers to restrict admissions to the service. This means that it can no longer admit people to live in the home. On 19 July 2018, CQC sent a Notice of Decision to cancel the provider’s registration of this location.

The provider appealed against this decision to the First Tier Tribunal (Care Standards) under section 32 (1) (b) of the Health and Social Care Act 2008. The appeal hearing was due to be held on 11 February 2019. The provider withdrew their decision to appeal and therefore the Notice of Decision was upheld. The location is no longer registered with CQC, and is no longer able to provide a regulated activity.

Other stakeholders including the local authority supported people and relatives to find other homes or alternative care arrangements.

Full information about CQC's regulatory response to any concerns found during inspection is added to reports after any representations and appeals have been concluded. You can see the enforcement action we took at the end of this report.

This service has a history of non-compliance with continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Seven inspections of this service had taken place since December 2014, three of these inspections with an overall rating of ‘Inadequate’ and four rated ‘Requires Improvement’.

This unannounced inspection took place on 10 September 2018. At this inspection, we found that there were four continued breaches relating to safe care and treatment, staffing, mental capacity and governance. There was one further breach of a regulation relating to safeguarding people.

We took enforcement action following an inspection of the service on 19 April 2017 where the service was given an overall rating of ‘Requires Improvement’ as we found the registered provider had continued to be in breach of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We placed conditions on the registered provider's registration to submit monthly reports to us setting out how they would assess, monitor and where required, take action to improve the quality and safety of the care and support provided to people living at Northgate House.

At the last inspection carried out on 7 March 2018, we found that there were continued serious concerns in relation to the quality and safety monitoring of the service. There was a continued failure to ensure people were protected from the risks associated with improper operation and management of the service including the premises. The service was in breach of seven regulations, which were Regulations 9, 11, 12, 14, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not provided with safe care. Oversight and management of the service was chaotic and disorganised. There continued to be insufficient governance arrangements in the service and therefore was still not effective in mitigating the risks to people's health, welfare and safety.

Following our comprehensive inspection on 7 March 2018, we formally notified the provider of our escalating and significant concerns. We asked the provider to inform us immediately of the urgent actions they would take with immediate effect to protect people and raise standards. We received a response to the urgent action letter on 12 March 2018, followed by an action plan addressing the concerns on 13 March 2018. This contained a basic action plan. We placed conditions on the provider’s registration to restrict admissions to the service. In response to our findings we notified the local safeguarding authority. Since our last inspection, the local authority has supported people who they commissioned care for to move to other locations.

At this unannounced inspection on 10 September 2018, we continued to have major concerns regarding the lack of action taken by the provider to ensure a safe service was provided. There was a continued lack of effective leadership and we found the provider continued not to have effective systems in place to provide safe, good quality care. There were three continued breaches and one further breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which we found, relating to safeguarding people. In addition, there was a breach of Regulation 18 of CQC Registration Regulations 2009.

The service continued to operate without a registered manager in post, and there had not been a registered manager for two years. 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 operations manager was currently acting as home manager and had submitted an application to register with CQC as the home manager. This application remains pending with CQC. For the purpose of the report we have referred to this person as the ‘manager’ throughout. There was a new deputy manager, who was not working on the day we inspected.

Risks to people’s safety and wellbeing had not always been identified and those that had been identified were not always mitigated. There remained concerns around medicines administration with no records around people’s prescribed topical creams and no guidance provided for staff for the administration of PRN (as required) medicines. Other medicines were given as prescribed.

Recent visits from environmental health inspectors and external auditors such as fire safety experts and a health and safety management auditor highlighted a number of areas where action was required by the provider to improve the safety of the environment and protect people from the risk of harm. Whilst the manager told us they had rectified these shortfalls, we found this was not always the case.

Staff had some knowledge of safeguarding from training, however people were not always properly safeguarded from the risk of abuse.

Accurate records of staffing available to meet people’s needs were not maintained. We were unable to ascertain exactly what hours staff had worked and when because the staffing was not accurately reflected in the rota. It was not clear from records maintained that all staff responsible for delivering personal care and support with mobilising people safely were competent in their roles. Staff received some training relevant to their role, however there was not always evidence of sufficient training for all staff delivering personal care. It was unclear whether there was consistent staffing at night to meet people’s welfare and safety needs.

The manager lacked understanding in their roles and responsibilities in relation to the Mental Capacity Act 2005. Best interests’ decisions were not always made when they were needed, and there remained a lack of understanding around consent. It was not clear how assessments of people’s capacity to consent to care were made.

Accurate, contemporaneous records of people’s care were not always kept because records did not reflect actual care delivered.

There continued to be poor leadership with a lack of effective oversight and governance of the service. The manager presented in a manner that lacked openness and transparency in carrying out the regulated activity. Health and safety checks were lacking and action had not been taken when external auditors had identified areas of risk to people’s safety.

There continued to be a high turnover of staff which did not provide continuity of care for people who used the service. There had been a further change of two managers since our last inspection. There were recruitment checks carried out to ensure that staff were suitable for the work they were employed to perform. However, the manager did not always maintain and record an oversight of staffs’ competency to ensure that staff remained suitably qualified to care for people in a safe way.

Care plans contained information about people’s hobbies, interests and social history. However, there was mixed feedback as to regularity of activities and the quality of support provided.

Relatives told us they could approach staff with any concerns, but they were not always resolved quickly. The provider had received some compliments.

There was a choice of meals available and people received enough to eat and drink. Staff supported people to access healthcare professionals and appointments.

The overall rating for this service is 'Inadequate' and the service remains in 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

You can see what action we told the provider to take at the back of the full version of the report.

There was no registered manager in post. A new manager had been appointed and they were due to take over the day to day management of the home the week after our inspection. They were present during the inspection. They told us that they would be applying for registration. 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.

Our previous inspection of this service took place on 30 November 2016 and had identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. These breaches related to the provision of safe care and treatment, safeguarding people from harm, consent and the management of the service.

Following the November 2016 inspection we imposed conditions upon the provider’s registration. One was to restrict the rate of admissions to the home. The other required the provider to report on the service’s progress on a monthly basis.

This April 2017 inspection found that the same four breaches remained as had been found at the November 2016 inspection, but that improvements had been made overall.

Some risks presented by hot water temperatures had not been remedied. The audits for scalding had failed to identify this. Staff had not secured drink thickener and were not using it when required for a person at risk of choking. The safety of one person who required staff to be present when they were outside the home had not been assured.

The service was not working in accordance with the Mental Capacity Act 2005. Some people had not consented to decisions that had been made about the care and support they received. Where people were unable to give consent to specific aspects of their care, there was no record to show that these decisions had been made in the person’s best interests.

The governance arrangements were not fully robust. Some audits were yet to be implemented following the recent engagement of a management consultancy team. Some audits required an improved level of scrutiny on completion. Staff lacked effective organisation and leadership of shifts. However, a new manager had been appointed and was due to commence their role the week after our inspection.

You can see what action we told the provider to take at the back of the full version of the report.

People’s medicines were managed and administered to them effectively and safely. There were enough staff to meet people’s needs. Recruitment processes needed improvement, but the management consultant told us that this was known about and action was planned.

Staff received the necessary training and had regular supervisions. People had access to healthcare professionals when needed. We received mixed views about whether people were offered choices about what to eat.

Staff were caring and kind. They treated people with respect and consideration. Staff attended promptly when people required their assistance and pre-empted people’s needs appropriately.

The service had undergone a period of considerable change since our previous inspection in November 2016. Much of this change had occurred in the six weeks prior to this inspection. However, we were satisfied that the recent engagement of the management consultancy team would help to bring about the necessary improvements.

This November 2016 inspection found that these concerns had been remedied, but different concerns had been identified in relation to the same regulation. These related to safe care and treatment. In addition, we found that the provider was in breach of three further regulations in relation to safeguarding, consent and the governance of the service.

Northgate House is a residential home providing accommodation and care for up to 22 older people. At the time of this inspection 14 people were living in the home.

There was a registered manager in post. 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.

Some risks to individuals’ welfare had not been appropriately acted upon. We had particular concerns with regards to how people were supported with behaviour that challenged. We also found that staff did not always identify and respond to the impact this behaviour had upon other people. Safeguarding referrals in relation to this had not been made when appropriate.

Improvements were required to ensure that staff understood how to implement the Mental Capacity Act 2005 and the related Deprivation of Liberty Safeguards into every day practice.

The provider oversight was focused on the environmental side of the service and improvements had been made here. However, they had limited oversight of the provision of care. The manager had delegated some responsibilities to a care co-ordinator but had not adequately overseen their duties. Some service audits were not effective.

Improvements had been made in the management of people’s medicines and people received their medicines as prescribed.

Staff received training in most areas. However, service users could have been better supported if staff had received training in managing behaviour that challenged. There was a lack of understanding in this area. People had enough to eat and drink and enjoyed their meals. People received support from healthcare professionals when any needs or concerns arose.

Staff were caring and people were treated with respect and dignity. People’s physical needs were attended to promptly. The provider had a complaints system in place and people, their representatives and other visitors to the service were encouraged to raise concerns.

Northgate House is a residential home providing accommodation and care for up to 22 older people. At the time of this inspection nine people were living in the home.

There was a registered manager in post. They were a partner in the business. However, they were not in charge of the home on a day to day basis. A new manager had been employed and they had commenced duties in March 2016 and are referred to as the manager throughout this report. They had applied for registration. We were told that the registered manager would apply to deregister once a new manager had been registered. 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 service had been placed into special measures following an inspection in June 2015 which had identified multiple breaches of requirements under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Due to the extent of our concerns we took urgent enforcement action to prevent further admissions to the home.

We last inspected this service in November 2015 and found that improvements had been made, but these were mainly in relation to the environment. The provider had still been in breach of regulations for personal care, consent, safe care and treatment, meeting nutritional and hydration needs, governance and staffing. As a result of the November 2015 inspection, the service remained in special measures.

This June 2016 inspection found that considerable improvements had been made. The provider was a partnership. Both partners in the business had relinquished their previous roles in the day to day management of the home. The provider was represented by the new operations manager. They had not previously been involved in the day to day running of the home. They had recruited a new manager. The operations manager and the manager had made considerable progress in improving the home which had benefited people living there. Whilst they acknowledged there was further work still to be done, they had stopped the decline in the service that our previous inspections had found and had begun to implement positive changes.

As a result of the improvements we found it was determined that the service is no longer in special measures. It was agreed with the provider to remove the restriction on admissions. Given the recent history of the service we will inspect the home again within six months to ascertain whether the improvements made have been sustained and whether progress continues.

This June 2016 inspection found that there were some concerns with the safe management of people’s medicines and that this constituted a breach of regulations. However, other risks to people’s well-being were consistently identified, planned for and reduced, as far as was possible.

Due to the service not always having sufficient staff numbers it needed to call upon if people were unable to come to work, some shifts were short staffed on occasion. The manager was aware of this issue and was in the process of recruiting more staff. They would be re-assessing staffing requirements on a fortnightly basis as people were admitted to the home. Most auditing procedures were robust, but a few improvements still needed to be made in relation to medicines management.

The practical aspects of implementing the Mental Capacity Act 2005 and the related Deprivation of Liberty Safeguards were not well understood. This required improvement. However, for day to day issues people were supported to make their own decisions when necessary and staff made decisions in people’s best interests when this was not possible.

Staff were supported and encouraged with their training. The manager was keen to enhance the qualifications and skills of all staff members. Staff had been offered additional in depth training in some subjects and there were opportunities for staff to specialise in some areas.

People received choices at mealtimes. Those who required direct assistance or encouragement to eat or drink received the support they needed. This had resulted in improvements in the nutritional health of some people who had previously been at risk of not eating enough.

The manager and operations manager had begun to create a more engaging culture in the home. People and their representatives were encouraged to participate in discussions about how people received their support from staff. People’s views were respected about how the home should be run and those that were able to had opportunities to be directly involved, for example, by helping to recruit staff.

People’s needs were identified and care plans were in place that gave detailed background information and clear guidance to staff on how best to support people. People were supported with social stimulation which had resulted in positive changes for them. Complaints were well managed, with verbal concerns, as well as formal complaints, being recorded and acted upon promptly. People and their representatives had confidence that any issues would be responded to appropriately.

The new leadership in the home was visible and people, their representatives and staff spoke positively of the changes that had been made. The service managers were developing links with the wider community for the benefit of people living in the home. They were enthusiastic and had clear plans to bring about further improvements in the home.

People who used this service may be at risk of unsafe care because risk assessments and care plans had not been reviewed or updated for three months. This meant that new or inexperienced staff did not receive current guidance on how to meet people's individual care needs.

We spoke with three people about the provision of food within the service. They were generally satisfied with the quality and quantity of the meals provided. This and the other evidence seen showed us that people were protected from the risks of inadequate nutrition and dehydration.

We had a tour of the service and noted that the premises were clean and that there were no unpleasant odours. This showed us that people were cared for in a clean, hygienic environment.

We spoke with two members of staff, one of whom had recently commenced their employment in the home. They confirmed that they had received an induction to the service and reported that they were up to date with their mandatory training. This showed us that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We found that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. We noted that nine staff had achieved their National Vocational Qualification (NVQ) level two or above and that new members of staff had commenced this training. Decisions about care and treatment were made by staff at the appropriate level. The individual care plans reviewed showed us that these were regularly monitored and reviewed by staff. A copy of the service's complaints policy and a separate complaint form was available in the service user's guide available in each person's bedroom. This showed us that people were given support by the provider to make a comment or complaint where they needed assistance.