Background to this inspection
Updated
28 March 2017
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.
This was an unannounced inspection which took place on the 26 October 2016. The inspection team consisted of three inspectors.
Prior to the inspection we reviewed the information we had about the service. This included information sent to us by the provider, about the staff and the people who used the service. We reviewed information on the Provider Information Return (PIR). This 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 notifications sent to us about significant events at the service. A notification is information about important events which the provider is required to tell us about by law.
During the visit we spoke with the Provider, the deputy manager, two people and four members of staff. We spent time observing how staff interacted and cared for people. We looked at a sample of four care records of people who used the service, medicine administration records and supervision records for staff. We looked at records that related to the management of the service. This included minutes of staff meetings and audits of the service. After the inspection we spoke with two relatives, one social care professional and the Quality Assurance team from the Local Authority.
The last inspection was on the 8 July 2015 where breaches were identified regarding the lack of systems in place to protect people from the risk of abuse, the lack of appropriate mental capacity assessments and the lack of governance. We also made recommendations around safe management of medicines and providing appropriate care for people living with dementia.
Updated
28 March 2017
This inspection was carried out on the 26 October 2016. The Limes provides personal care and accommodation for 16 older people. There are people at the service that are living with dementia. Bedrooms are situated on the ground and first floor. Access to the first floor is by a stair lift. At the time of our inspection there were 13 people living at the service.
The registered manager had recently left the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Instead we were supported on the day by the Provider and the newly appointed deputy manager.
There were not always enough staff deployed in the service to consistently meet people's needs. People were left on their own for long periods of time without the support of staff. Not all of the care staff on duty provided care to people; some were undertaking kitchen and laundry duties which left one member of staff to provide the care for 13 people.
Risk assessments for people were missing and other assessments were not always detailed. There was not enough information to guide staff in how to reduce the risks to people. Incidents and accidents were not always recorded and those that were recorded lacked detail and actions put in place to reduce the risk of incidents. Staff were not following good infection control. There were aspects to the environment that were not safe for people including windows in a bedroom that did not open. The premises and equipment was not well maintained. However people’s medicines were managed in a safe way
Although staff and the provider had knowledge of safeguarding adult's procedures they were not putting this into practice. Safeguarding incidents were not always being reported to the local authority. There was a safeguarding adult's policy in place however staff were not following this. People who had capacity were having their liberties restricted.
People's rights were not always met under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect them from harm. Assessments had not been completed specific to the decision that needed to be made around people's capacity. DoLS applications had been submitted to the local authority around whether people's liberties were being restricted however these had also been submitted for people who had full capacity.
People were not always receiving care from staff who were competent, skilled and experienced. There was a risk that people were receiving care from staff who were had not had training to meet the needs of people with mental health issues or behaviours that may challenge others. Staff competencies were not always assessed as they did not have appropriate supervision or appraisals.
People at risk of dehydration or malnutrition did not always have effective systems in place to support them. People were not always provided choices that met their reasonable preferences. Where people's food intake needed to be recorded this was not being done even when people’s weights had fallen. People had not always have access to health care professionals to support them with their health needs in a timely way.
Staff at the service did not always treat people with dignity and respect. There were times where people were ignored for periods of time throughout the day and people's dignity was not always maintained. People were not always consulted about the care they wanted. The routines of the home were imposed for staff convenience rather than to meet the personal choices of people. We did see times when staff were caring and considerate to people and relatives did say that staff were caring to their family members.
People's preferences were not consistently being sought by staff. The provider was not always responsive to people's needs. There was no detailed information in people's care plans around the support they needed. There was a lack of detail around care for people with a mental health diagnosis.
There were not enough activities on offer specific to the needs of people. There were long periods of time where people had no meaningful engagement with staff. People that wanted to go out did not always have the opportunity.
There were not effective systems in place to assess and monitor the quality of the service. Although some audits had been undertaken these had not been used to improve the quality of care for people. Records were not always completed or accurate. Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The provider had not informed the CQC of significant events.
There was a complaints procedure in place however not everyone knew how to access this. Complaints were not always appropriately responded to.
Recruitment practices were safe and relevant checks had been completed before staff started work.
Personal evacuation plans were in place for every person who lived at the service. In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this time frame. 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.