Background to this inspection
Updated
14 November 2020
The inspection
This was a targeted inspection to check specific concerns we had received since the registered manager had left the service and in relation to the management of medicines, staffing and safeguarding. We will assess all of the key question at the next comprehensive inspection of the service.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was undertaken by two inspectors.
Service and service type
Harpers Villas Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service did not have a manager registered with the Care Quality Commission. A registered manager means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced. We completed a site visit on the 12 October 2020 and telephone calls were undertaken on the 16 October 2020 to relatives.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
During the inspection
We spoke with three people who used the service and two relatives about their experience of the care provided. We spoke with two members of staff, the deputy manager, manager and the office manager.
We reviewed a range of records. This included four people’s care records and three people’s medication records. We looked at one staff file in relation to recruitment. We reviewed a variety of records relating to the management of the service.
After the inspection
We continued to seek clarification from the manager to validate evidence found. We looked at training data and quality assurance records.
Updated
14 November 2020
About the service
Harpers Villas Care Centre is a care home providing personal care to 26 people aged 65 and over. At the time of the inspection 17 people lived at the service. People who used the service had a range of support needs related to old age and dementia. The accommodation is organised into three floors, however the top floor was not in use at the time of the inspection.
People’s experience of using this service and what we found
People were not sufficiently protected from the risk of harm, including potential abuse, risks associated to health conditions and the behaviour of others. People did not always receive their medicines as prescribed. People told us there were not enough staff to meet their needs and our observations confirmed this.
The management of the service was inadequate as the provider did not carry out robust checks to ensure that care was being delivered safely and effectively. Audits were carried out by the management team and provider, but they had failed to ensure that people were always safe and their needs were being met. As a result, people were exposed to the risk of harm.
We received mixed feedback from people in respect of meals. Meal times were functional rather than a pleasant social experience. Guidance from healthcare professionals were not always followed to ensure people’s needs were met. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
People did not receive support that was consistently caring and respectful. Care given was task centred rather than person-centred and not all needs were met.
People had limited opportunities to be involved in meaningful activities. People and relatives felt able to make a complaint but did not always receive a satisfactory response. People’s personal wishes during their final days had not been fully explored.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Requires Improvement (published 30 October 2018) and we identified a breach of regulation 17, good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had not been made and the provider was still in breach of regulation 17 and further breaches were also identified. The overall rating of the service has deteriorated to Inadequate.
Why we inspected
The inspection was prompted in part by notification of a specific incident. Following which a person using the service sustained a serious injury. The information CQC received about the incident indicated concerns about the management of falls. This inspection examined those risks.
We have found evidence that the provider needs to make improvements. Please see the safe section of this full report.
Enforcement:
At this inspection we have identified breaches in relation to safe care and treatment, safeguarding, good governance and staffing. The inspection also identified breaches in relation to the provider’s failure to notify the commission when Deprivation of Liberty Safeguards (DoLS) were authorised as is required. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up: Special Measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.