Archived: Sevington Mill

Updated 31 July 2019

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 1 and 2 November 2018 and was unannounced. The inspection team consisted of two adult social care inspectors and an expert-by-experience on the first day. The expert-by-experience had personal understanding of older people and those living with dementia. On the second day there were two adult social care inspectors.

Before our inspection we reviewed the information we held about the service including previous inspection reports. We did not ask the service to complete a Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

We considered the information which had been shared with us by the local authority and other people, looked at safeguarding alerts and notifications which had been submitted. A notification is information about important events which the provider is required to tell us about by law.

We met and spoke with 14 people who lived at Sevington Mill and observed their care, including the lunchtime meal, medicine administration and activities. 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 with us. We spoke with four people’s relatives throughout both days. We inspected the environment, including communal areas, bathrooms and some people’s bedrooms. We spoke with five care and senior care staff, the cook, the manager, the provider and a healthcare professional.

During the inspection we reviewed 10 people’s care plans and associated records. We also looked at other records, these included staff training and supervision records, staff recruitment records, medicines records, risk assessments, accidents and incident records, quality audits and policies and procedures. At the end of the inspection we asked for some information to be sent to us, we were not sent all the information we requested.

We displayed posters in the communal areas of the service inviting feedback from people and relatives. Following this inspection visit, we did not receive any further feedback.

Updated 31 July 2019

This inspection took place on 1 and 2 November 2018 and was unannounced. We re-inspected this service earlier than planned due to concerns that had been raised about people’s safety and the support they were receiving.

Sevington Mill 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. Sevington Mill can accommodate 50 people. At the time of our inspection there were 36 people living at the service.

Accommodation is spread over 2 floors in a large detached property. There was a large communal lounge, dining area and conservatory where people could choose to spend their time.

There was no registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had been appointed in June 2018, they had applied to CQC to become registered as the manager at the time of this inspection.

Sevington Mill was last inspected June 2018. At that inspection it was rated as 'Requires Improvement' overall. At that inspection we found some improvements had been made, however their remained ongoing breaches of the Health and Social Care Act Regulated Activities Regulations 2014 in relation to Regulation 11; need for consent, Regulation 12; safe care and treatment and Regulation 17; good governance. Following that inspection the service was removed from Special Measures. We asked the provider to send us a report to tell us what actions they would take to ensure the ongoing breaches of regulation were met.

At this inspection we found that the improvements we saw in June 2018 had not been embedded or sustained. We found that there were continued breaches of regulation, along with a number of new breaches.

People were not kept safe from abuse or avoidable harm. Not all staff had received safeguarding training. Staff were able to tell us how to recognise and report safeguarding concerns. However, in practice they had not consistently reported concerns to management. Incidents and accidents were not fully analysed or reviewed by the manager and risk assessments had not been updated. Staff did not reflect and learn from accidents and incidents and there was a lack of reporting to the local authority or the Care Quality Commission (CQC).

Risks to people were not properly assessed. Risk assessments were not in place for skin integrity, falls or supporting people when their behaviour challenged, despite risks being known.

There were not enough staff to meet people’s needs and the provider had not used a recognised dependency tool to determine safe staffing levels. Staff were not recruited using safe and robust recruitment processes to assess the candidate’s suitability for the job.

Medicines management was not consistently safe. Temperature checks were not completed. Creams and ointments were not consistently stored safely and medicines were not always disposed of in a safe manner, in line with best practice. People did not always receive their medicines when they needed them, and those who ‘self-medicated’ were not assessed to ensure their competence.

Other areas of medicines management had improved. Medicine records were completed accurately, contained photos and guidance for staff. Medicine audits were completed by senior staff; and had identified some of the shortfalls we found. Competency checks were completed for staff responsible for administering medicines. Checks on the environment and equipment were completed.

People had not received full assessments of their needs and care planning did not consistently refer to best practice or evidence-based guidance to ensure effective outcomes were achieved. Staff had not received effective training, supervision, or appraisal to carry out their roles. Training in key areas such as behaviour that could challenge, end-of-life care or dementia care was insufficient and staff had not been assessed to ensure they had the appropriate skills and competencies to support people.

The management of nutrition and hydration was not effective. Food and fluid monitoring was not accurate nor consistently completed for each person who needed it. The service worked with healthcare professionals to ensure people received appropriate medical input, however guidance implemented as a result of this was not followed by staff. People’s healthcare needs were not always met. Staff did not always recognise or respond promptly when people were unwell.

People had not been supported to have maximum choice and control of their lives. The registered provider, manager and staff did not fully understand the principles the Mental Capacity Act 2005 and the policies and systems in the service did not support people to find the least restrictive options. Restrictions had been assessed incorrectly and DoLS applications had been submitted lawfully but the registered manager had made applications for each person without considering their individual needs appropriately.

Staff were busy and rushed, which often meant people’s emotional needs were not met. Through our observations we saw that staff mostly treated people with kindness. They recognised most people's needs well and caring interactions were seen. However, staff were not able to spend quality, meaningful time with people because they were too busy. People's involvement in care decisions and planning was not clearly evidenced. There was little adaptation to the premises to make them suitable for those living with dementia.

The service was not meeting the accessible information standard (AIS) and some people’s care plan documentation was not written in a way they could understand. Complaints were not responded to effectively and there was no information about how to make a complaint available in an accessible format to meet the needs of people living with dementia.

Activities were limited. People sat in chairs, either in their rooms or the communal areas, for most parts of the day with little stimulation. People were not appropriately supported at the end of their lives. End of life care plans were basic and not based around the person’s wishes.

The manager and registered provider failed to ensure that staff shared a clear vision for providing high quality person-centred care. The culture of the service was not empowering for people, relatives, or staff.

The service was not well led. Governance systems were not effective and service audits were not analysed to give oversight of the service or followed up to ensure that improvements were made. Statutory notifications had not consistently been submitted to the CQC. Staff had not been supported or their skills and knowledge developed and little work had been done to encourage learning and best practice from working in partnership with other professionals and health care providers.

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 timeframe. 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.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are considering our regulatory response to our findings and will publish our actions when this has been completed.