Archived: Cornwallis Court

Updated 21 April 2017

Cornwallis Court provides nursing and residential care for up to 74 older freemasons and their dependants. The service is split into three units, residential, nursing and Geoffrey Dicker House. Geoffrey Dicker House is a separate building which is part of Cornwallis Court and is specifically for people living with dementia.

There were 70 people living in the service when we inspected on 10 and 11 January 2017. This was an unannounced inspection.

There was a registered manager in post. 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 are currently investigating an incident where a person fell on an exposed pipe and sustained burns and will report on this once the investigation is complete.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of this report.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Not all risks to people living in the service were being identified. Improvements were needed to ensure that all risks in people’s daily living were assessed and these assessments provided staff with information about how to effectively manage and minimise these risks. This included environmental risks and those linked to health conditions. Where risk assessments had been carried out they were not always completed fully to include relevant and detailed guidance for staff.

Incidents such as falls had not been consistently reviewed by the provider so that preventative actions could be considered and put into place where needed.

People generally received their medicines safely and had access to healthcare professionals such as GP’s, dentists and chiropodists when required. However, improvements were required to provide guidance to staff regarding as and when required medicines.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not always support this practice. There was not always reference to the Mental Capacity Act 2005 (MCA) to promote people's rights and where people were unable to give their consent, best interest decisions were not always recorded as having taken place.

Care plans, as identified by provider's own audits, were contradictory and had not always been updated as people’s needs changed.

A complaints procedure was in place, however not all complaints had been recorded.

There was a lack of oversight of the service by the provider to ensure the service delivered was safe. Although the provider had some quality assurance systems in place, these had not been effective in allowing the management team to identify concerns and take the required action. Improvements were required around the effective auditing of health and safety.

Safe and effective recruitment practices were followed to check that staff were of good character, physically and mentally fit for the role and able to meet people’s needs.

People were safeguarded against the risk of abuse as the staff were trained to recognise abuse. This was supported by appropriate safeguarding and whistleblowing policies.

Updated 21 April 2017

Cornwallis Court provides nursing and residential care for up to 74 older freemasons and their dependants. The service is split into three units, residential, nursing and Geoffrey Dicker House. Geoffrey Dicker House is a separate building which is part of Cornwallis Court and is specifically for people living with dementia.

There were 70 people living in the service when we inspected on 10 and 11 January 2017. This was an unannounced inspection.

There was a registered manager in post. 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 are currently investigating an incident where a person fell on an exposed pipe and sustained burns and will report on this once the investigation is complete.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of this report.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Not all risks to people living in the service were being identified. Improvements were needed to ensure that all risks in people’s daily living were assessed and these assessments provided staff with information about how to effectively manage and minimise these risks. This included environmental risks and those linked to health conditions. Where risk assessments had been carried out they were not always completed fully to include relevant and detailed guidance for staff.

Incidents such as falls had not been consistently reviewed by the provider so that preventative actions could be considered and put into place where needed.

People generally received their medicines safely and had access to healthcare professionals such as GP’s, dentists and chiropodists when required. However, improvements were required to provide guidance to staff regarding as and when required medicines.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not always support this practice. There was not always reference to the Mental Capacity Act 2005 (MCA) to promote people's rights and where people were unable to give their consent, best interest decisions were not always recorded as having taken place.

Care plans, as identified by provider's own audits, were contradictory and had not always been updated as people’s needs changed.

A complaints procedure was in place, however not all complaints had been recorded.

There was a lack of oversight of the service by the provider to ensure the service delivered was safe. Although the provider had some quality assurance systems in place, these had not been effective in allowing the management team to identify concerns and take the required action. Improvements were required around the effective auditing of health and safety.

Safe and effective recruitment practices were followed to check that staff were of good character, physically and mentally fit for the role and able to meet people’s needs.

People were safeguarded against the risk of abuse as the staff were trained to recognise abuse. This was supported by appropriate safeguarding and whistleblowing policies.