Archived: Carr Hall Care Home

We last inspected Carr Hall Care Home in July 2016. At that inspection, we found that people's safety was being compromised in a number of areas. This included how people's medicines were managed, managing risk of fire and infection, a lack of person centred care, safe care and treatment. There was also a failure to ensure staff received appropriate support, training, supervision and appraisal, a failure to undertake robust employment checks and a failure to provide good governance. Following that inspection the provider sent us an action plan detailing the improvements they would make in the home.

During this inspection we reviewed actions the provider told us they had taken since our last inspection to gain compliance against the breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified.

During this inspection we found the governance arrangements in the home were not effective enough to rectify the breaches found at the previous inspection. Insufficient improvements had been made and the provider had not followed the action plan and undertakings that they provided us after July 2016 inspection. The provider was still in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to person centred care, safe care and treatment, staffing, fit and proper persons and good governance.

We found that there had been a further deterioration in the quality of care in other areas, which meant the provider was in breach of a further three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were in relation to seeking consent, maintaining the premises and equipment and failure to notify Care Quality Commission of significant events that affected the smooth running of the service. This meant that risks to people had increased.

Enforcement action was taken by the Commission in light of the significant work needed within the home to improve the quality and safety of the service being provided. The enforcement action was to prevent the service provider admitting new people to the home whilst those changes took place.

The overall rating for this service is 'Inadequate' and the service is therefore 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, it 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.

Carr Hall care home is registered to provide accommodation and personal care for up to 23 who are older people, have a physical disability or people living with a dementia. Nursing care is not provided. All rooms were of single occupancy and of these six were ensuite. Bedrooms were located across two floors of the home. At the time of our inspection there were 20 people who lived at the home.

The service was managed by a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

People’s medicines had not been managed safely. Guidance for safe management of medicines had not been followed which included secure storage of medicines and a lack of robust recording for topical creams and thickening powders. The systems in place to monitor the use of medicines were not effective and regular medicines audits had not been conducted. Our visit on the 09 October 2017 identified that support had been provided by the local Clinical Commissioning Group and issues we identified had started to be addressed. An action plan had been provided by the medicines management team. The registered manager had started to address some of the concerns found however no formal medicines audits had been undertaken.

Risks to people were not managed in a safe way. People were offered an inconsistent approach following head related injuries as there was no clear guidance in place for staff to follow. We saw no evidence to demonstrate that action had been taken to seek advice from medical professionals after people had incurred head injuries. People could not be assured that they would receive appropriate support following a fall. During our visit of on 09 October we found that a falls management policy had been put in place and up to date falls protocols had been introduced and staff had started to follow these. However this needed time to be embedded to ensure consistence.

We looked at the risk assessments in place for people who used the service and these included skin and pressure area care, falls, moving and handling, mobility and nutrition. However we found shortfalls in other areas of risk management, including a failure to provide staff that were first aid trained. The risk assessments had not been completed and reviewed consistently when people’s needs had changed. We found similar inconsistencies with care plans.

When potential safeguarding incidents had been recorded we did not see these had been reported in line with local safeguarding procedures. There was safeguarding policy however this was not robust and did not reflect current practice and legislation. A significant number of staff had not received training in safeguarding adults. However staff we spoke with showed awareness of signs of abuse and what actions to take. During our visit of on 09 October we found that staff had received first aid training and risk assessments for two people at risk of choking had been updated and those at risk of falls had been referred to relevant professionals. However a significant number of care records were yet to be reviewed. The local authority safeguarding team had visited the home and were reviewing risks in the service.

People were not effectively protected in the event of a fire. Building fire risk assessments and Personal Emergency Evacuation Plans (PEEPS) were in place. However no fire drills had been undertaken since February 2014. We had previously asked the provider to take action about this during our inspection in July 2016. At this inspection in September 2017 we found there were obstructions on fire exits and fire doors had been wedged. We reported our findings to the service to the local fire safety department. During our visit of on 09 October we found that a fire safety inspection had been carried out by the fire safety officers. The fire safety officers found several concerns including shortfalls in the fire risk assessment, the fire doors and poor fire safety practices. They requested the provider to take action. On our visit on 09 October we found the provider had started to address some of the concerns however these had not been completed.

The provider had not adequately maintained and repaired the premises in a timely manner. We found the roof had been leaking for approximately 19 months. Attempts to repair had been made however we expected this to have been rectified. The water pressure in some rooms was very low preventing people from having access to hot water. Equipment had been maintained and serviced in line with regulations and manufacturer’s recommendations. Infection control measures were not robust and required further improvements. The premises had not been adapted to ensure that they were dementia friendly. During our visit of on 09 October we found the roof had not been fixed however the provider had ordered materials required to fix the roof. They informed us they had been a delay with the delivery. An electrician had assessed the risk of water ingestion in the electric systems and isolated the light fittings in the area affected. A specialist had reviewed the concerns with water pressure and ongoing investigations on how to rectify this were ongoing.

Safe recruitment practices were not always followed to help ensure only suitable people worked in the home. Guidance on safe recruitment had not always been followed.

People using the service had access to healthcare professionals as required, to meet their needs. We found

Carr Hall care home is registered with the Commission to provide nursing or personal care for up to 23 who are older people, have a physical disability or people living with a dementia. Nursing care is not provided. At the time of our inspection there were 20 people in receipt of care. All rooms were of single occupancy and of these six were ensuite. Bedrooms were located across two floors of the home.

There was a registered manager in post on the day of our inspection. 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. We last inspected the service on 19 March 2013 and identified no breaches of the regulation that was relevant at that time.

During this inspection we identified breaches in relation to medicines, risk assessment, the environment and equipment, infection control, recruitment, staff training, records, activities and good governance. We also made recommendations in relation to staffing, Deprivation of Liberty Safeguards, activities and nutrition and hydration. You can see what action we told the provider to take at the back of the full version of the report.

We saw staff had completed medication training and people using the service, visitors and professionals told us they had no concerns with the administration of medicines. However we identified concerns in relation the safe handling, administration and recording of medicines.

Staff we spoke with were able to discuss the appropriate actions they would take if they suspected abuse was taking place and they were aware of the whistleblowing policy (Reporting bad practice). People using the service, Visitors and professionals told us they had no concerns and that people were safe. There was evidence that staff had completed safeguarding training.

There was evidence of environmental risk assessments in place however there was no evacuation plans or any assessment of peoples individual need in the event of an emergency evacuation. Bedrooms had personal items and mementos in them and people who used the service we spoke with told us they liked their rooms. All rooms were tidy and free from clutter; however we identified concerns relating to a strong odour present in one bedroom and also from a chair in the lounge.

Staff files included some evidence of safe recruitment however there were gaps in the records which included a lack of interview questions and one file that had no Disclosure Barring Service (DBS) check. We saw evidence of appropriate staffing numbers in place, however we observed the lounge area was left unattended on a number of occasions throughout our inspection.

Care files reflected people likes and dislikes for meal choices and there was some evidence of nutritional assessments in place. However we saw gaps in weight recording and staff we spoke with told us there were no alternative measures in place to monitor any changes in weight.

Professionals visiting the home told us they were confident staff had appropriate skills and staff we spoke with confirmed training was taking place. We saw some evidence of the training undertaken in the staff files we looked at, which included nationally recognised qualifications. However the training matrix identified some gaps in mandatory training such as fire safety, infection control and Mental Capacity Act and Deprivation of Liberty Safeguards.

We were told no people living in the home were subject to a Deprivation of Liberty Safeguard (DoLS). We saw that staff had access to policies and procedures relating to DoLS, however staff we spoke with about DoLS were unable to demonstrate they had appropriate knowledge to protect people who used the service from unlawful restrictions. We saw no training had been provided to ensure staff had the necessary knowledge to protect people.

People who used the service and visitors to the home were positive about the care delivered in the home and we saw evidence of people’s individual care needs recorded in their care files. We observed some staff responding in an appropriate and timely manner however we observed two occasions where care was not delivered in line with individual requirements.

Staff had access to policies to guide them on supporting the privacy and dignity of people who used the service and the provider’s statement of purpose demonstrated a commitment to ensure people’s privacy and dignity was maintained. Professionals visiting the home told us they were offered private facilities when undertaking care delivery or treatment.

We were told people were involved in the development of their care files. We looked at the care records for three people currently in receipt of care at the home. There was evidence of care planning and risk assessments in place, however we noted some areas of the care file required review and updating. One person’s care file identified the use of equipment was required with moving and handling, however we observed this was not used during care delivery on the day of our inspection.

Staff told us activities were taking place in the home however we could see no documentation of completed activities to confirm this. There were no activities undertaken during the day of our inspection other than one person who was supported to go outside to undertake a specific activity with them.

We saw evidence of meetings taking place for people who used the service; however there was no evidence to confirm formal and detailed staff team meetings took place. Staff we spoke with told us they received updates on an informal basis. We received positive feedback from staff as well as professionals who visited the home about the registered manager.

The was evidence of some audits and monitoring taking place however we noted a number of these had not been completed in full and dates of completion were recorded a number of months ago. Systems and processes to ensure quality monitoring was taking place to ensure the safety of the services provided was lacking.

Formal structured staff supervision was not taking place. We only saw evidence of one supervision record in the staff files we looked at. Staff we spoke with told us supervisions were undertaken, one staff member said these were done informally.

People were being involved as far as possible in planning and consenting to their support and were enabled to make decisions about matters which affected them. This meant people's consent to their individual care and support was not properly agreed and confirmed with them.

We found people experienced some good care and treatment. They told us they were treated with respect. People were getting support with their healthcare needs and they had ongoing attention from health care professionals.

We found there were usually enough experienced and skilled staff available to provide care and support. However we found progress could be made on making sure there were always enough staff on duty.

People were satisfied with the facilities and accommodation provided at Carr Hall. However, we found some matters in need of attention to promote the well-being of people using the service.

There were systems in place to help support people to make complaints and raise concerns. Some improvements were needed to sure people have up to date information.

This inspection showed recording keeping had improved to promote good care practices and better communication.

We found improvements had been made with care assessments and care plans. However, further progress was needed with ensuring the care planning process supports effective, safe care.

Progress had been made with staff training and supervision. However further attention was needed with staff appraisals to make sure employees are properly supported and developed.

Better systems had been introduced to check and monitor the services and facilities at Carr Hall. Arrangements had been made to consult with people on their experience of the service as part of a quality assurance process.

However, we found there were some shortfalls in assessing and planning for people's care, staff training and checking the quality of the service. This meant people may not receive safe, appropriate care.

People were treated with respect and valued as individuals, they were able to make choices and maintain their independence skills.

They told us they liked the food provided and they had choice menus.

People had no concerns about their care and treatment; they said they felt safe with the staff.

They told us they liked the staff, describing them as 'Nice' and 'Very good'.