Archived: Valentine Lodge

Updated 13 May 2016

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 inspection took place on 30 March 2016 and was unannounced. The inspection was undertaken by two inspectors.

Before the inspection, we looked at all of the information we had received about the service. This included information we received prior to the inspection and notifications from the provider. Statutory notifications include information about important events which the provider is required to send us by law.

We spoke with the deputy manager, the provider’s personal assistant and six members of staff working at the service. In addition, we spoke with two people who used the service. We primarily looked at the provider’s arrangements for medicines management and their arrangements for monitoring and assessing the quality of the service provided. We also looked at the care plans for six people who used the service.

Updated 13 May 2016

We carried out an unannounced focussed inspection of this service on 6 January 2016 and 7 January 2016 to check compliance against the actions required from the comprehensive inspection completed on the 24 August 2015. We found that the provider had not completed the actions as laid out in their action plan to ensure safe medicines management or ensure that there was an effective quality assurance and governance system in place. Two warning notices were issued on 29 January 2016 to the provider. A suspension of placements by the Local Authority had been imposed on 22 January 2016, following our inspection on 6 January 2016 and 7 January 2016.

The Care Quality Commission met with the registered provider on 3 February 2016 and 14 March 2016 to discuss our on-going concerns. Although during these meetings and other exchanges the provider gave assurances that things would improve, information of concern continued to be shared with us from the Local Authority. Despite visits by the Local Authority and local Clinical Commissioning Group to ensure peoples’ welfare, they continued to have significant concerns and were not seeing improvements and stability at the service.

We undertook a focused inspection on 30 March 2016 to check compliance with the warning notices and to confirm that the provider now met legal requirements. At the time of this inspection there were 14 people using the service.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by the Care Quality Commission. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

On 30 March 2016, in response to the seriousness of their level of concern regarding the safety of the service provided to people, the Local Authority terminated their contract with the registered provider and steps were taken to move people living at Valentine Lodge.

Valentine Lodge provides accommodation, personal care and nursing care for up to 20 older people and people living with dementia.

A registered manager was not in post at the time of our focussed inspection on 30 March 2016. The deputy manager was in day-to-day charge of the service and they were supported by the provider’s personal assistant. 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.

This report only covers our findings affecting requirements relating to the medicines management and assessing and monitoring the quality of service provision. You can read the report of our last comprehensive inspection by selecting the ‘all reports’ link for Valentine Lodge on our website at www.cqc.org.uk

The standard of medicines management at the service was not safe and medicines had not always been administered in line with the prescriber’s instructions or effectively recorded for the protection of people living at Valentine Lodge. Actions as outlined within the registered provider’s action plan received by the Care Quality Commission on 6 November 2015 to ensure safe medicines management had not been addressed and these remained outstanding.

We found that the registered provider’s arrangements so as to ensure that an effective system was in place to regularly assess and monitor the quality of the service provided was ineffectual and unproductive. The registered provider was unable to demonstrate how they measured and analysed the care provided and how this made sure that the service was operating effectively and safely so as to ensure good outcomes for people living at Valentine Lodge. The registered provider did not have regard to our previous inspection reports, the information contained within them and the significant improvements required so as to improve the service by learning from adverse events and incidents to establish what caused them.