28 and 29 September 2015
During a routine inspection
The inspection took place on 28 and 29 September 2015 and was unannounced.
Following this inspection, the provider submitted an application to the Care Quality Commission (CQC) to cancel their registration of the service. This was because the service was being sold to an established provider already registered with the CQC. The CQC continued to monitor the service and liaise with relevant agencies to ensure people were kept safe during this period of time. The CQC facilitated a swift cancellation of the outgoing provider's registration and registration of the service under the new provider. The provider of the service, at the time of this inspection, relinquished control of the service on 28 October 2015.
The service provides care for older people who are physically frail and who live with dementia. The service can accommodate up to 35 people. At the time of the inspection 16 people who required nursing care lived at Charnwood House.
We found the registered manager had left the service on 4 September 2015. 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. A nurse who had been employed just prior to the registered manager leaving was in the position of trying to manage the service but with limited resources. A representative of the provider based themselves in the home three days a week.
Local adult social care and health care commissioners had visited the service and found significant shortfalls in people’s care. They had shared these concerns with the Care Quality Commission.
We found ten regulations not met. They included: not ensuring people’s safety and well-being, not designing care which met people’s individual needs, not ensuring good infection control, a lack of staff numbers, a lack of staff training, delivering care without consent and adhering to relevant legislation, not ensuring people’s dignity and showing them respect, poor management of concerns and complaints and poor overall governance systems.
People’s care and health needs not been appropriately met. In particular, risks relating to pressure ulcer development, wound care, nutrition and poor posture had not been robustly identified or properly managed. Some people’s weight had not been correctly monitored and they had lost weight without it being noticed. Some people had wounds which had not been correctly assessed and this had an impact on how these were being managed. Staff lacked skills and knowledge to manage these risks effectively. People had not received the care they needed to prevent further deterioration in their health and well-being. Following this inspection, these risks were reduced by commissioners placing appropriate health care professionals in the home to work on a daily basis.
Whilst staff tried to act in a caring manner, they lacked the skills and time needed to support people in a compassionate manner. People received little support to interact with others and appeared withdrawn and low in mood. Inconsistent practice and a lack of knowledge had resulted in people not being sufficiently and appropriately protected under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
Staff lacked support and adequate training to meet people’s needs. Problems with staff retention and a lack of staff recruitment had resulted in a depleted staff team. Nurses worked no more than one or two shifts per week and the service was heavily reliant on agency staff. As a result, effective communication about people’s needs did not happen. Inconsistent practices were taking place and care staff were not receiving appropriate guidance. Care staff had no senior structure to their team so inexperienced care staff received little direction and guidance. There were not enough staff to meet people’s needs and therefore necessary care was not always being provided. Staff recruitment practices were not robust enough to fully protect people from those who may not be suitable to care for them.
Poor monitoring systems had resulted in people’s well-being and safety not being maintained. Although the registered manager had completed audits, and the provider told us they talked with her about these, this process had not been robust enough to prevent the systemic failings identified during this inspection. There was no evidence of a program of on-going improvement and learning. The provider had not carried out effective monitoring checks and was unaware of the number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 not being currently met.