Archived: Sheldon Lodge

Updated 30 March 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Prior to this inspection we received information of concern about the provider not following up an allegation of abuse in an appropriate and timely way. In addition, concerns were raised about staff not following the provider procedures and contacting appropriate medical services in an emergency. Unsafe moving and handling practices by staff and adequate staffing levels on some night shifts.

We carried out an unannounced inspection on the 31 January and completed the inspection on the 1 February 2017. The inspection was carried out by two inspectors and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

We spoke with seven people and with three visitors about their views on the quality of care and support received. We spoke with both of the providers, one of whom is also the registered manager. In addition, we spoke with three care staff and the cleaner. We looked at seven people’s care records, which included people who had previously lived at the home. We also reviewed documentation in relation to the management of the home. This included staff training and recruitment records and quality auditing processes. We looked around the premises and observed interactions between staff and people who used the service.

Before our inspection, we looked at previous inspection reports and notifications we had received. Services tell us about important events relating to the care they provide using a notification.

Updated 30 March 2017

The inspection was unannounced and carried out on 31 January and completed on the 1 February 2017. Sheldon Lodge provided accommodation with personal care for up to a maximum of ten people.

There was a registered manager in place who was also one of two providers whose legal entity was a partnership. 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.

Prior to this inspection concerns were raised to us about people's safety. We found the provider had not responding appropriate to an allegation of abuse. People were not protected from the risk of harm due to the lack of timely medical intervention and people were placed at risk due to unsafe moving and handling practices by staff.

People received their medicines on time and medicines were stored safely. However, the provider did not follow the least restrictive action when administering medicines.

There was a lack of activities and meaningful occupation and there was no documentary evidence that the activities which did take place were planned and evaluated for their effectiveness.

We saw some positive interactions between staff and people however there were some staff practices which demonstrated a lack of empathy.

People had a care plan in place however we found they were not involved in the review of their care plan. Care plans and other documents were not being updated in order to ensure current information was accessible, particularly when providing guidance to staff.

The provider had failed to notify the Commission when required to do so, in relation to a change in their legal entity and notifications in regarding incidents.

Staff training had fallen behind as had staff supervision. Staff had received an annual appraisal.

The provider was not adhering to the principals of the Mental Capacity Act 2005 and we found that people were not involved in the decision making process.

The provider had a system in place for auditing the quality and standard of the service they provided, however these had not been completed to highlight potential shortfalls in the delivery of the service. People and families were not involved in how the service was run and were not asked for their opinion about this.

Staff reported they felt well supported by the provider and were able to approach them if they had any concerns.

Following the inspection, the provider notified us they were closing the service and submitted the relevant notifications to the commission as required.

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, 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.