Archived: Korniloff

Updated 19 May 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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.

The inspection took place on 23 and 24 April 2018 and was unannounced. The inspection was carried out by two adult social care inspectors.

The inspection was prompted in part by safeguarding concerns we had received via the local authority safeguarding team. These included concerns about people receiving poor care, staff not recognising when people were unwell, concerns about staffing levels and concerns about medicine management and the leadership at the service. We did not look at these specific investigations as part of the inspection; however, we did use this information to inform us about how we needed to conduct this inspection and areas of care we needed to review as part of the inspection process.

Prior to the inspection we reviewed the records held on the service. This included the Provider Information Return (PIR) which is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed previous inspection reports and notifications. Notifications are specific events registered people have to tell us about by law.

During the inspection we spoke and / or met with the 11 people living at the service. We spoke with the provider who was also the registered manager and six staff. We spoke with visiting professionals from the local authority and one visiting district nurse.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk to us. We undertook this observation in the communal lounge. We observed how people spent their day and the interactions they had.

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After our inspection, because of identified concerns, we told the provider to send us an action plan and assurances about people’s safety. We also informed the commissioners and local authority safeguarding team about our immediate concerns.

Updated 19 May 2018

The last inspection took place on 14 November 2017 and was rated “Good” in all areas.

We undertook an unannounced, focused inspection of Korniloff on 23 and 24 April 2018. The team inspected the service against two of the five questions we ask about services: Is the service Safe and Well Led? This is because we had received concerns from the local authority and safeguarding team about people’s care at Korniloff.

Korniloff is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Korniloff is a residential care home providing accommodation and personal care for older adults. The service is set in a converted hotel on the coast, offering spacious communal areas to make the most of the wide stunning views of the sea and Burgh Island. The service does not provide nursing care. The home uses community nurses to provide this service. The home can accommodate a maximum of 17 people but as the provider does not use two rooms as doubles, the actual capacity is 15 people.

At the time of the inspection 12 people were living at Korniloff, one person was in hospital. The provider was also the registered manager who lived on site. 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 the inspection we had received concerns from the local authority safeguarding team. These included concerns about; poor and neglectful personal care, poor care in relation to management of people’s skin and risk of falls, poor medicine management, failure to recognise and respond effectively in response to changes in people’s health needs, environmental concerns and concerns about the leadership at the service.

A safeguarding meeting had taken place with the local authority prior to the inspection and we were told a number of safeguarding investigations in relation to these areas of concern were on-going. We did not look at these specific investigations as part of the inspection, however, we did use this information to inform us about how we needed to conduct the inspection and areas of care we needed to consider and review.

The local authority had also informed us prior to the inspection, that due to the high number of concerns received, they had met with the provider and requested an improvement plan and assurances about people’s safety. Due to the concerns, the provider and commissioners agreed to stop any admissions to the home. The provider also agreed to stop admitting any privately funded people.

We found the systems in place to keep people safe from harm were poor. There were not good medicine practices in place. Staff had not been trained to administer medicines and had little knowledge of why people were on particular medicines. There were no medicine audits in place and no individual protocols about how people should receive their medicines. We found people did not always have their medicine at the right time, some had missed their medicine and some had too much medicine given to them. These were areas of concern.

People’s risks were not known, documented or well managed at the service. People at risk of falls, weight loss or skin damage were not assessed. Skin care management was poor and inconsistent. People were not repositioned frequently and did not always have the equipment they needed to help prevent skin breakdown.

Accidents were recorded but no one reviewed accidents and incidents which had occurred. This meant opportunities to analyse and prevent risk were missed.

People were at risk from staff that had not received a thorough induction, training and ongoing monitoring of their skills. Some staff had not received medicine training, fire training and moving and handling training. This affected their practice in these areas and put people at risk.

Staffing levels were not always safe. The provider did not have a dependency tool to assess what safe levels of staffing should be.

The environment was not safe and presented risks to people.

The leadership at the service was ineffective. Communication within the service was poor. People at the service did not have opportunities to suggest ideas and raise their views.

Quality assurance processes were minimal and did not drive change.

Following the inspection we took immediate action to ensure people were safe. We told the provider to give us assurances that people were safe in relation to medicines, moving and transferring, staffing levels, management of falls and skin care and the security of the property. The provider worked closely with the local authority to provide us with assurances within the timescale requested.

However, during the course of the inspection, the provider gave notice to the local authority commissioners to end their contract. The provider also submitted an application to the Commission to cancel the registration of the service. This meant they would no longer be providing care to people. Following the inspection, on 4 May 2018 the local authority confirmed to the Commission all people had been moved from Korniloff.