Archived: Centenary House

Updated 13 June 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

Two inspectors carried out the inspection over one day.

Service and service type

Centenary House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided. There had been no on-site managerial cover since at least mid-February 2020.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection in November 2019. This included details about incidents the provider must notify us about. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

We used the information the provider sent us in the provider information return. This is information 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 seven people who used the service and two relatives about their experience of the care provided. The majority of people we spoke with could not provide us with detailed information. We spoke with three members of staff including the deputy manager, care workers and the chef.

We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at one staff file in relation to recruitment; this was because only one person had been recruited since the last inspection. We looked at three staff files in relation to staff supervision and a variety of records relating to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We spoke with local authority professionals who visited the service.

Updated 13 June 2020

About the service

Centenary House is a residential care home and was providing personal care to nine people aged 65 and over at the time of the inspection. The service can support up to 13 people. All bedrooms are on the ground floor and there is access to a communal lounge and conservatory.

People’s experience of using this service and what we found

People we spoke with were unable to provide us with detailed explanations of life at the home.

There were widespread and systemic failings identified during the inspection. The quality and safety monitoring systems used by the provider were not fully effective in ensuring the quality of service provision and that people were protected from avoidable harm.

The provider had failed to make appropriate statutory notifications; safeguarding incidents had not been identified and reported. Notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been managed.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the systems in the service did not support this practice.

At the time of inspection there was no registered manager in place. There were also not enough suitably qualified staff to ensure people received safe and effective care. People did not receive adequate levels of personal care and were seen to be unkempt.

Care plans did not contain sufficient information to ensure people received person centred care. The guidance within peoples' risk assessments was not always followed by staff and records used to monitor peoples' health were not always completed. This exposed people to risks of neglect and unsafe or inappropriate care or treatment.

People had access to healthcare professionals however, the provider could not be assured staff would be able to identify when referrals were required as associated documents were incomplete.

Procedures for the administration and the disposal of medicines had not been completed as required. Medicine errors were not recorded and audited.

The environment including the kitchen, laundry and people’s bedrooms were unclean and not maintained effectively; there was an infection control risk to people using the service. Fire risk had not been appropriately managed and access to the communal environments for people in wheelchairs had not been considered.

People did not receive a balanced and nutritious diet, there was little access to fruit and vegetables.

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 8 January 2020). This service has been rated requires improvement for the last seven consecutive inspections. The service has now further deteriorated to inadequate.

Why we inspected

The inspection was prompted in part due to concerns received about staffing, medicines and poor diet. A decision was made for us to inspect and examine those risks.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Centenary House on our website at www.cqc.org.uk.

Enforcement

We have identified eight breaches in relation to staffing, consent, safeguarding, risk assessments, care planning and activities, governance, dignity and respect and recruitment at this inspection.

Following the inspection, we placed a restriction on the provider’s registration to prevent them from admitting people to the service

Follow up

Shortly after the inspection, the provider put in an application to close the service, which was processed by the CQC; the home was closed and is no longer registered with the CQC. The local authority assisted in moving people to other suitable services.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service was put into ‘special measures’ post inspection. This usually 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. However the provider made the decision to close the service shortly after the inspection.

Usually 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 the 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.