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Archived: Ryecroft Private Residential Care Home Inadequate

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Inspection report

Date of Inspection: 11 December 2014
Date of Publication: 20 February 2015
Inspection Report published 20 February 2015 PDF | 83.23 KB

Overview

Inspection carried out on 11 December 2014

During an inspection in response to concerns

This inspection was conducted in response to concerns raised with us by the Local Authority in relation to medicine management and the staff recruitment practices operated at the home. We used this information to plan our visit.

At the time of our inspection, a manager was employed at the home who was not registered with the Care Quality Commission. This meant that the manager's fitness to be the registered manager had not been assessed by the Care Quality Commission.

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.’

The inspection team who carried out this inspection consisted of an adult social care inspection manager and an adult social care inspector. During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with two people who used the service, the provider, the manager, a team leader, two care staff and the Local Authority. We also reviewed records relating to the management of the home which included three care records, a sample of medication records and six staff files. Below is a summary of what we found. The summary describes what people using the service, the provider and the staff told us, what we observed and the records we looked at.

Is the service safe?

The service was not safe. We looked at six staff files. We found that appropriate checks in relation to the safety and suitability of staff to work with vulnerable people had not been made prior to their employment.

We looked at the three people’s care records and found they contained insufficient information about people’s needs. Care was not adequately planned or risks properly identified and managed. This placed people at risk of receiving inappropriate and unsafe care that did not meet their needs.

Staff we spoke with shared their concerns about the care they were providing to one person who lived at the home. We reviewed this person’s care. We found that the person’s care had not been planned and the care provided was unsafe. For example, the provider did not have any moving and handling equipment in place to enable staff to safely meet the person’s mobility needs. This placed both the person and staff at risk of serious harm.

Medicines were poorly managed. Some people did not receive their medication when they needed them and some people did not receive some of their medication for significant periods. We observed a medication round in progress. The administration of medication was disorganised and unsafe. Staff records showed that all staff training in medicine administration was out of date. Records relating to the administration of medication were poor and inaccurate and medicines were not always stored securely. This meant people’s health and wellbeing was placed at serious risk.

Is the service effective?

The service was not effective. We found care plans did not provide sufficient detail to ensure people’s needs were met. Risks to people were increased as staff were provided with little information about what people’s risks were, how to manage them and how to respond to the risk should it occur.

For example, one person had dementia and sometimes displayed behaviour that posed a risk to themselves and others. The person’s care plan however failed to identify and provide any guidance to staff on how to support the person with dementia effectively so that they were able to communicate their needs and wishes. The risk management tools recommended by the person’s social worker had also not been used consistently to effectively monitor and safely manage any unwanted behaviours.

Is the service caring?

The service was not always caring. We observed staff supporting people throughout the day and noted they spoke pleasantly and treated people kindly and with respect.

We found however that people’s social and emotional needs were not always considered in the planning and delivery of care. For example, one person at the home was immobile. We visited the person and saw that they were sat in their bedroom with no television or radio and no means of accessing the communal areas downstairs for company. The person told us “I don’t want to be here”.

Is the service responsive?

The service was not responsive. People’s individual needs were not consistently met. For example, one person at the home was unwell and had not received their newly prescribed medication in a timely manner. We asked the team leader about this, who confirmed the medication had not yet been obtained. Two other people at the home had also not received all of their required medication as the home had run out of stock. This demonstrated that people’s health and welfare needs were not responded to appropriately or in a timely manner.

Is the service well led?

The service was not well led. The provider did not have effective systems in place to ensure that people’s needs and care were assessed, planned and delivered appropriately and in a safe manner. There were no robust procedures in place to ensure that staff employed were suitable for their job roles and the provider did not have appropriate arrangements in place to protect people from the unsafe use and management of medications.

We found that the provider had failed to provide satisfactory management and leadership in the delivery of the service which placed people at serious risk.

We had major concerns about the service during our visit. We discussed these with the new manager in post and the provider. We also made two safeguarding referrals to the Local Authority in relation to two people’s medication issues.