Archived: Stadium Court Care Home

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.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The service is registered to provide accommodation and personal care for up to 168 people. At the time of this inspection, care was delivered to people across four separate units. These units were named; Spode, Stafford, Wade and Wedgwood. Spode, Stafford and Wade units provided long term care to people and Wedgwood unit provided short term care and rehabilitation. People who used the service may have a physical disability and/or mental health needs, such as dementia. At the time of our inspection 116 people were using the service.

At this inspection, we found that the required improvements had not been made and we identified new and continued Regulatory breaches. The service has been rated as ‘inadequate’ overall and will remain in special measures.

The home did not have a registered manager. However, the newly appointed home manager had applied to be registered with us and their application was being assessed at the time of our inspection. 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 and associated Regulations about how the service is run.

At this inspection, we found that the provider did not have effective systems in place to consistently assess, monitor and improve the quality of care. This meant that poor care was not always being identified and addressed by the manager or provider.

Risks to people’s health, safety and wellbeing were not consistently identified and managed and people did not always receive their care in accordance with their care plans. Medicines were not managed safely.

Staff were not always effectively deployed to consistently meet people’s needs in a safe and timely manner. Staff, in particular agency staff did not always know people’s individual needs and care preferences in order to provide safe and responsive care and support.

Incidents of potential abuse and neglect were not always recorded and reported in line with local and national guidance. This meant people were not always protected from the risk of abuse and neglect.

Staff received some training to help them support people. However, there were significant training gaps that left people at risk of receiving poor, unsafe care.

People were supported to access health and social care professionals in response to changes in their health and wellbeing needs. However, advice from professionals was not always followed in a timely manner to promote people’s health, safety and wellbeing.

People’s capacity to consent to their care was not always assessed and we could not always see that the requirements of the Mental Capacity Act 2005 were followed when people were unable to consent to their care. Some people had restrictions placed upon them that had not been assessed and planned for to ensure their rights were protected. We saw that restrictions placed on people were not always requested through the Deprivation of Liberty Safeguards (DoLS) when people could not consent to their care.

People were not always involved in the assessment and planning of their care. This meant people sometimes received care that did not meet their care preferences.

Staff did not always provide care and support in a manner that promoted people’s dignity. People were not always supported to make choices about their care.

Social and leisure based activities were promoted. However, some people felt these did not always meet their individual needs.

Written complaints were managed in accordance with the provider’s policy. However, effective systems were not in place to ensure verbal complaints were consistently recorded and acted upon to improve people’s care experiences.

Safe recruitments systems were in place. However, improvements were needed to ensure the provider could assure people that agency staff were suitable to work at the service.

People were provided with food and drink. However, staff did not always support people to make informed meal choices.

People’s right to privacy was promoted.

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.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We undertook this unannounced comprehensive inspection on 26 and 27 April 2017 to check that the required immediate improvements had been made. You can read the report from our previous inspections, by selecting the 'all reports' link for Stadium Court Care Home on our website at www.cqc.org.uk.

At this inspection, we found that some of the required improvements had been made. However, two of the seven previously identified breached of Regulations from the December 2016 inspection were still present and the service was rated as ‘inadequate’ in the well-led domain. As a result of this, the service will remain in special measures.

The service is registered to provide accommodation and personal care for up to 168 people. Care is delivered to people across five separate units. People who use the service may have a physical disability and/or mental health needs, such as dementia. At the time of our inspection 130 people were using the service.

The home did not have a registered manager. However, the home manager had applied to be registered with us and their application was being assessed at the time of our inspection. 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 and associated Regulations about how the service is run.

At this inspection, we found that the provider did not have effective systems in place to consistently assess, monitor and improve the quality of care. This meant that poor care was not being always identified and rectified by the manager or provider.

Risks to people’s health, safety and wellbeing were not consistently identified, managed and reviewed and people did not always receive their care in accordance with their care plans. Medicines were not managed safely.

Safety incidents were not always analysed and responded to effectively, which meant the risk of further incidents was not always reduced.

Staff were not always effectively deployed to consistently meet people’s needs and promote people’s safety. People did not always receive their care in accordance with their care preferences and needs.

Staff were recruited safely and they knew how to recognise and report abuse. However, improvements were needed to ensure potential abuse was consistently reported in a prompt manner.

People were supported to access health and social care professionals in response to changes in their health and wellbeing needs. However, advice from professionals was not always followed in a timely manner to promote people’s health, safety and wellbeing.

People were supported to eat and drink. However, people were not always supported to receive the specialist diets that they had been prescribed by health professionals. People who required specialist diets were not always offered the same level of food choices that people who required regular diets received.

Staff received some training to help them support people. However, there were significant training gaps that left people at risk of receiving poor, unsafe care.

Some staff knew people well which enabled them to have positive interactions with people. However, the information needed to provide consistent person centred care was not always recorded for new or temporary care staff to follow. People were not always involved in reviewing their needs and the information contained in their care records.

People were enabled to participate in indoor based leisure and social based activities that met their personal preference. However, further improvements were needed to ensure people could access outdoor spaces and the community when they wished to do so.

Most people described the staff as kind and caring. However, some people were concerned that staff did not always have the time needed to have quality, caring interactions with them.

There were gaps in end of life care training. However, systems were in place to enable people to receive pain free and dignified end of life care.

People’s right to privacy was promoted.

The requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were followed to ensure people decisions about care were being made in people’s best interests when they were unable to make these decisions for themselves.

Complaints were responded to and acted upon to improve people’s care experiences.

There was a positive staff culture as staff were aware that there had been shortfalls in the quality of care. All the staff we spoke with told us they were committed to improving the quality of care.

The service is registered to provide accommodation and personal care for up to 168 people. People who use the service may have a physical disability and/or mental health needs, such as dementia. At the time of our inspection 140 people were using the service. Five of these people were receiving in patient care at a local hospital. This report refers to our findings from inspecting three of the five units at Stadium Court. The three units we inspected were; Stafford, Spode and Aynsley. We were unable to inspect Wade unit due to an infection outbreak. Wedgwood unit was not included in this focused inspection because the inspection was completed in response to safety concerns that only related to the other four units.

We inspected three of the five units at Stadium Court. These Stafford, Spode, Aynsley and Wade. We spent time on Stafford, Spode and Aynsley unit, but were unable to inspect Wade unit due to an infection outbreak.

The service had a registered manager. However, they were no longer working at the home. 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 and associated Regulations about how the service is run. A new manager had been appointed and they had been working at the home for approximately two weeks. The new manager told us they planned to register with us.

At this inspection, we identified a number of Regulatory Breaches. The overall rating for this service is ‘Inadequate’ and the service has therefore been placed into ‘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.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At this inspection, we found that the provider did not have effective systems in place to assess, monitor and improve the quality of care. This meant that poor care was not being identified and rectified by the provider.

Risks to people’s health, safety and wellbeing were not consistently identified, managed and reviewed and people did not always receive their planned care.

Medicines were not always managed safely and people could not be assured that they received their medicines as prescribed.

People were not protected from the risk of infection as the environment, furniture and equipment was not consistently clean and hygienic. Some staff did not understand how to protect people from infections.

People were not always protected from the risk of abuse because suspected abuse was not always reported as required. Safe recruitment systems were not in place to ensure staff were of suitable character to work with the people who used the service.

Safety incidents were not always responded to effectively, which meant the risk of further incidents was not always reduced. There were not always enough suitably skilled staff available to keep people safe and meet people’s individual care needs.

The registered manager and provider did not always notify us of reportable incidents and events as required.

Stadium Court is registered to provide accommodation and nursing care for up to 168 people. People who use the service have physical health and/or mental health needs, such as dementia. At the time of our inspection 114 people were using the service over four separate units (Wade, Stafford, Spode and Aynsley).

The service had a registered manager. 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 and associated Regulations about how the service is run.

We found that some improvements were needed to ensure people could consistently participate in leisure and social activities that met their preferences.

People’s safety was maintained because risks were assessed and planned for and the staff understood how to keep people safe. Improvements had been made to the way medicines were managed. This meant people were protected from the risks associated with medicines.

There were sufficient numbers of staff to keep people safe. Staff received training that provided them with the knowledge and skills to meet people’s needs effectively.

Staff sought people’s consent before they provided care and support. When people did not have the ability to make decisions about their care, the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed. These requirements ensure that where appropriate, decisions are made in people’s best interests when they are unable to do this for themselves.

People were supported to access suitable amounts of food and drink of their choice and their health and wellbeing needs were monitored. Advice from health and social care professionals was sought and followed when required.

Staff treated people with kindness and compassion and people’s dignity and privacy was promoted. People were encouraged to make choices about their care and independence was promoted.

People and their relatives were involved in the planning of their care and care was delivered in accordance with people’s care preferences. People’s feedback was sought and used to improve the care.

People knew how to make a complaint and complaints were managed in accordance with the provider’s complaints policy.

There was a positive atmosphere within the home and the manager and provider regularly assessed and monitored the quality of care to ensure standards were met and maintained.

We saw there were systems in place to keep people safe. People received assessments to identify their needs and plans were in place to guide staff on how to provide care.

People who used the service who could speak with us, and their relatives told us they were treated in a caring manner and their privacy and dignity were respected. One person said, 'The girls all talk so nicely to me, they never shout or get cross. They always knock if I'm in my room'. One relative told us, 'They are very caring here and have time to talk to my relative'.

We saw that staff worked with other services to maintain people's health and wellbeing. One relative said, 'They always get professionals out if X (person who used the service) is unwell'. We saw evidence to confirm the staff responded to changes in people's needs by seeking professional advice and support.

The service was well led. Effective systems were in place to enable the quality of care to be assessed, monitored and improved. We saw that feedback from people was used to improve the care, support and treatment delivered.

In this report the name of a registered manager, Miss Sandra Bradbury appears, who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

We observed staff providing support in the home and saw people were treated with dignity and respect. Personal care issues were discussed sensitively and discreetly. There was information about people's care needs including their preferences and how they wanted care provided.

The expert by experience talked to people using the service and looked at what happened around the home. They saw how everyone was getting on together, and what the home felt like. They saw people were involved in meaningful recreational activities and staff talked to people about things that were important to them.

Relatives were able to continue to play an active role and support people and provide care. The people we spoke with said they felt safe and protected from potential harm. They said the staff provided sensitive and flexible personal care support and they felt well cared for.