Archived: Clevedon Court Residential Home

Updated 14 June 2019

The inspection:

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

The inspection was prompted in part by notification of two incidents about people subject to Deprivation of Liberty Safeguards who had left the service unobserved.

Information shared with CQC about the incidents indicated potential concerns about the management of risk of people leaving the premises without necessary support. This inspection examined those risks.

Inspection team:

The inspection team consisted of three adult social care inspectors and one expert by experience. Two adult social care inspectors visited on each day of the inspection. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert by experience’s area of expertise were older people and people who have a learning disability.

Service and service type:

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection:

Inspection site visit took place on 07, 08 and 21 May 2019. The first and third days of the inspection were unannounced, the second day of the inspection was announced.

What we did:

We reviewed various records including, the training matrix, files for three employees, seven care plans, audits, and complaints. We spoke with 17 people who were using the service, three relatives and seven staff, including the registered manager, deputy manager and three care staff. We completed a tour of the service with the registered manager and deputy manager.

We made ten safeguarding alerts to the local authority safeguarding team about concerns identified during the inspection. We reviewed comments submitted by the registered manager after the inspection.

Updated 14 June 2019

About the service: Clevedon Court Residential Home is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is registered to provide care and support for up to 22 people with learning disabilities, autism and older people. At the time of our inspection there were 20 people using the service.

People’s experience of using this service:

People who needed to be kept safe through continuous supervision had left the home unobserved placing them at risk. Staff did not have access to guidance about actions to take if a person was missing from the service. Suitable action had not been taken to prevent a reoccurrence.

People were at risk from potential harm and abuse. Safeguarding referrals were not consistently made to the local authority safeguarding team when allegations of abuse were made, or incidents were witnessed in the service. Incidents were not investigated, or action taken to keep people safe. Unexplained injuries, including unexplained bruising, had not been investigated appropriately or referred to the local authority safeguarding team.

People were at risk of injury from hazards in the environment relating to poor maintenance. Risks from scalding water had been identified, however the risks had not been assessed or managed. The registered manager could not provide assurances or evidence about which taps had been fitted with temperature control valves. Some wardrobes had not been secured placing people at risk.

Some medicines prescribed ‘as required’ were not being managed safely to ensure people received these correctly.

Following the inspection, we wrote to the provider and registered manager requiring them to take urgent action to address these risks and protect people from further risks.

The environment had not been properly maintained and there were malodours in areas of the home. Decorating works that had been completed were of a poor standard. There were discarded items in the garden, including an old cistern.

People did not have consistent access to meaningful activities. The service had identified that this was an area for development and had taken actions to improve this, including ordering horse shoes for people to decorate and arranging for a performer to visit the service.

Staff did not consistently receive training in line with the provider’s list of mandatory training. Staff were not receiving regular appraisals as the registered manager had suspended them to focus on areas they assessed as more important. Staff were recruited safely and received regular supervision sessions.

There was a programme of quality audits and provider checks in place. However, these had not been used effectively as issues found by inspectors during the inspection were not recorded in the corresponding audit. Audits lacked detail and effective improvement plans had not been developed as a result.

There were not enough suitably qualified staff deployed across the service to meet the needs of people.

The service did not consistently submit statutory notifications to the Care Quality Commission.

We observed some kind and caring interactions between staff and people However, we also observed some undignified interactions between staff and people. People’s wishes were not always listened to or acted on.

Questionnaires had recently been sent to people, relatives and staff. The registered manager was reviewing the responses received. No recent meetings for relatives or people had occurred. During our inspection a large team meeting took place.

The registered manager had responded to complaints in a timely manner and spoken with staff involved when required. Relatives told us they could approach the registered manager with their concerns.

Food looked appetising and people were offered a choice of meals. People and relatives spoke positively about food at the service.

Rating at last inspection: Inadequate (published March 2019)

At the last inspection we identified nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009.

We asked the provider to submit copies of monthly reports for areas of particular concern. The provider had been submitting this information to the Commission.

Why we inspected: This inspection was brought forward due to information of risk and concern; we received information that two people subject to Deprivation of Liberty Safeguards had left the home unobserved.

Enforcement: We identified five continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one continuing breach of the Care Quality Commission (Registration) Regulations 2009.

This inspection identified one new breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

Follow up: 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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk