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Archived: Harbour Close Inadequate

We are carrying out a review of quality at Harbour Close. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 28 October 2016

We undertook a focused inspection of Harbour Close on 26 and 28 July 2016.

At the comprehensive inspection of this service in November 2015 we found the provider was meeting all the regulations we looked at and was rated as a GOOD service.

This focused inspection was carried out to look at concerns raised by Halton Council with regard to staffing levels and leadership of the service.

This report only covers our findings in relation to the Safe, Responsive and Well-Led domains.

You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Harbour Close on our website at

8 -11 Harbour Close is a purpose-built care facility providing personal care and accommodation for 12 people who have physical disabilities. The service consists of four bungalows each accommodating three people. The bungalows are owned by Liverpool Housing Trust and the service is managed by Scope. The home is located in the Murdishaw area of Runcorn and is within easy access of local amenities including shops, social and educational facilities. There is also a small office located adjacent to bungalow 10 which is used by staff to store and access information.

There was no registered manager at Harbour Close. 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 found that since our last inspection the registered manager had left the service and the staffing levels were now a cause for concern. We were aware that concerns had been raised by Halton Council regarding the staffing and overall governance of the service.

We identified breaches of the relevant regulations in respect of person centred care, safe care and treatment, safeguarding service users from abuse and improper treatment, staffing, good governance and notifications to the Commission.

Care plans were not person centred and did not provide enough information to direct staff in the care they needed to deliver. We found that a number of agency staff were employed that had difficulties in understanding the needs of people living at the home and staff told us that they did not have time to read the care plan and risk assessments. People did not receive care that met their individual needs and preferences.

Risk assessments were out of date and did not include full details of any action taken to minimise avoidable harm. We saw some examples of unsafe practice that put people living at the home at risk of harm. We identified a number of incidents and issues that should have been referred to the local authority’s safeguarding team. These had not been referred and we had not been notified about them.

There were insufficient staff employed to safely meet the needs of people living at the home.

The registered provider was aware of many of the shortfalls in practice because the local authority had previously carried out quality monitoring visits and implemented an action plan. However, leadership and management of the home had failed to address many of the issues.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by the Commission. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six mon

Inspection areas



Updated 28 October 2016

The service was not safe.

The health and well-being of the people who lived at the home was at risk because the service were failing to provide care in accordance with each person�s assessed needs.

Managers and staff were not doing all that was reasonably practicable to identify, control and mitigate risks and ensure that people were protected from unsafe and ineffective care.

There was an insufficient numbers of suitably, experienced qualified and competent staff to ensure the well-being of the people who lived at the home.



Updated 15 February 2016

The service was effective.

Staff were trained and supported to meet the needs of the people who used the service. The principles of the Mental Capacity Act 2005 (MCA) were understood by staff and appropriately implemented.

People were supported to maintain good health and had access to appropriate services which ensured they received on-going healthcare support.

People were provided with enough to eat and drink. People’s nutritional needs were assessed and they were supported wherever possible to maintain a balanced diet, although this was balanced against people’s choice.



Updated 15 February 2016

The service was caring.

People had their privacy and dignity respected and staff supported them to maintain their independence.

People experienced positive, caring relationships with staff.

People were involved in making decisions about their care and these were respected.



Updated 28 October 2016

The service was not responsive.

The registered provider failed to ensure that care and treatment was provided which meet people�s individual needs.

People were not provided with social activities which resulted in their social isolation.

Risk assessments and care plans did not accurately reflect any identified risk to people�s health and wellbeing.



Updated 28 October 2016

The service was not well led.

There was no registered manager of the service and staff were unsure of who was leading the service on a day to day basis.

The registered provider had not taken effective action to address care practice failings identified by health and social care professionals so vulnerable people had remained at risk of receiving unsafe care.

The registered provider had failed to ensure that systems and processes were established and operated effectively to assess, monitor and improve the quality and safety of the service.