About the service Providence Court is a residential care home providing personal to up to 61 people. The service provides support to older people, some of whom are living with dementia, in one adapted building. At the time of our inspection there were 51 people using the service.
People’s experience of using this service and what we found
People’s safety was not always well managed. Infection control practices were not followed effectively even though the staff knew what they needed to do. This was in relation to cleaning regimes, handwashing and face mask wearing. Some carpets and chairs needed to be cleaned as they were grubby, and paintwork was chipped making cleaning more difficult. The home was in a COVID-19 outbreak at the time of inspection and the management team were not sure about the numbers of people Covid-19 positive in the home, or which units were affected. However, most staff did know who had tested positive.
Staff did not have prompt access to people’s individual needs and risks due to a shortage of handheld devices which gave them access to this information. Insufficient action had been taken to get these issues resolved. Changes to people’s health needs were not always recognised by staff and appropriate action was not always taken. We found several examples of relatives needing to prompt medical intervention.
Pressure relieving equipment to help support people’s skin integrity, was not always checked by staff to ensure it was set correctly. People’s needs were not always met in a timely way by staff to reduce risks. Medicines were not always managed safely. People had to wait too long for pain relieving medicines. People told us they felt safe and staff knew how to report concerns. However safeguarding risk management had not been followed in one instance.
People’s dignity was not promoted. Staff left a door open with a person in full view of a communal area while using the toilet and staff spoke loudly about supporting people with care needs.
People, relatives and staff said there was not always enough staff to meet people’s needs. People told us most staff were nice, but busy. We saw examples of people waiting for care needs and a member of the regional support team needed to step in to provide care. We also found that some staff training was not up to date or in place. For example, diabetes awareness. Some, but not all relatives were confident about the standard of care and told us staff were friendly.
People had access to food, drink and call bells throughout our inspection. However, while we saw that there were records kept of fluids consumed, for some people cared for in bed, we noted drinks did not change in quantity for most of the morning.
The management systems in the home were in place, however had not been effective to address the shortfalls found during this inspection. Feedback about the management was mixed, staff felt there was a lack of support, guidance and leadership which had impacted on morale and culture in the home. People and relatives gave mixed views about how responsive management had been to concerns and leadership. The home had had four managers in the past year. The new manager started the day prior to the inspection and was on their induction.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.
Rating at last inspection
The last rating for this service was good (published 6 June 2018).
Why we inspected
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 undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received standards of care, response to changing health needs, management and staffing. A decision was made for us to inspect and examine those risks.
We inspected and found there was a concern with safe care and robust leaderships so we widened the scope of the inspection to become a comprehensive inspection which included the key questions of safe, effective, caring, responsive, and well-led.
The overall rating for the service has changed from good to inadequate based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see all sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Providence Court on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to safe care and treatment, safeguarding, dignity and respect, staffing and governance systems at this inspection.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
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.
Special Measures:
The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’. This 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.
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.