Archived: Horncastle House

Horncastle House 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. Horncastle House accommodates up to 43 people in one adapted building. There were 23 people using the service during our inspection. Horncastle House provides nursing care to older people; most of whom live with dementia or memory loss.

Services operated by the provider had continued to be subject to a period of increased monitoring and support by commissioners. As a result of concerns raised about other locations operated by the provider, the provider is currently subject to a police investigation.The police investigation is ongoing and no conclusions have yet been drawn. There have been no specific criminal allegations made about Horncastle House at the time of our inspection. Since May 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find. Our findings from inspections of other locations operated by the provider also informed the planning of the inspection of Horncastle House.

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 (CQC) 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. The former registered manager had left in September 2017 and their deputy had taken over the management of the service. They had applied to the CQC to become registered but had then left the service in April 2018. A peripatetic manager had been in place for 11 weeks prior to our inspection. A new manager was started work at Horncastle House on 13 August 2018 but had yet to apply to become registered with the CQC.

Horncastle House was last inspected in August 2018. At that inspection it was rated as 'Inadequate' overall and ‘Requires Improvement’ for Caring and Responsive domains. These were the same ratings as had been applied following an inspection in March 2018. There had been little improvement between the inspections of March and August and we had continued to find that risks to people’s safety and well-being had not been adequately monitored or reduced. We had been sufficiently concerned during the August inspection, to request immediate action was taken by the provider and that confirmation of these actions was confirmed in writing.

Despite the CQC being given these assurances, at this inspection we found that known risks to people had increased rather than reduced. This had left people exposed to immediate risk of serious harm or death.

The service was unsafe for the people living there, because risks from choking, lack of access to their call bell, from falls, poor hydration management, improper use of pressure-relieving equipment and the environment had not been remedied since our last inspection. We found a level of risk to people that was extreme and required urgent action.

There were not enough experienced and competent staff deployed to meet people’s needs, and a heavy reliance on agency staff remained. Staff practice was observed to be poor but had been unchallenged by managers or the provider.

Information and records about people’s care needs were dangerously inaccurate and conflicting; making them unworkable as guidance to staff, many of whom were from agencies and did not know people well.

There was evidence of a lack of learning from previous CQC inspection findings, feedback and reports to improve the safety of the service.

The service was not well-led. Auditing and oversight by the management team and provider had been ineffective and had not checked that staff practice was keeping people safe.

Assurances had been given to the CQC about improvements which had not been made. Staff culture had deteriorated and inappropriate and unsafe actions were going unchecked and unchallenged.

The provider continued to display the incorrect rating for the service on their website and the CQC had not been notified of the death of a person using the service; which is a statutory requirement.

We found continued breaches of three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We will publish information about our actions when we are able to do so.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

This inspection took place on 7 and 8 August 2018 and was unannounced.

Horncastle House 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. Horncastle House accommodates up to 43 people in one adapted building. There were 26 people using the service during our inspection. Horncastle House provides nursing care to older people; some of whom are living with dementia.

Since our last inspection, services operated by the provider had continued to be subject to a period of increased monitoring and support by commissioners. As a result of concerns raised about other locations operated by the provider, the provider is currently subject to a police investigation. There have been no specific criminal allegations made about Horncastle House at the time of our inspection. However, we used the information of concern raised by partner agencies about this provider to plan what areas we would inspect and to judge the safety and quality of the service. Since May 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find. Our findings from inspections of other locations operated by the provider also informed the planning of the inspection of Horncastle House.

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 (CQC) 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. The former registered manager had left in September 2017 and their deputy had taken over the management of the service. They had applied to the CQC to become registered but had then left the service in April 2018. A peripatetic manager had been in place for 11 weeks prior to our inspection. A new manager was due to start work at Horncastle House the week following our inspection.

Horncastle House was last inspected in March 2018. At that inspection it was rated as 'Inadequate' overall and ‘Requires Improvement’ for Caring and Responsive domains. At this inspection, there had been improvements in some areas, but we continued to find that risks to people’s safety and well-being had not been adequately monitored or reduced. As a result, we found continued breaches of Regulations across all areas we inspected.

The service was not consistently safe and there were not enough staff deployed to meet people’s needs. Not all identified risks to people had been appropriately minimised. New risk assessments were in place for choking and behaviours that may challenge but staff practice in these areas did not keep people safe or monitor them for changes and trends.

There was evidence of a lack of learning from incidents in that actions arising from safeguarding investigations had not been embedded so that people were kept consistently safe going forward.

The service was not effective. There had been improvements to staff training in some subjects such as epilepsy and first aid but other training was not as effective as it could be. Agency staff continued to make up many staff on shift on some occasions and were not always knowledgeable about people’s needs.

Feedback about meals provided was poor and people did not always have support to eat and drink when they needed it. Weights charts had been miscalculated by staff, which made it appear that some people had lost very large amounts of weight, when they had not. These miscalculations had not been picked up by managers. People were referred for dietetic input when they had lost weight however.

Staff knew how to care for skin wounds but records about this were not always available and repositioning of people to relieve pressure had not always happened in line with care plan directions. Not all individual medical conditions had been incorporated into care plans so that staff could ensure people’s treatment was appropriate.

The service was not fully meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act (MCA) 2005 because applications for DoLS had not been made for people who would need to be prevented from leaving the service alone for their own safety.

The service was not consistently caring because people’s needs were not always properly considered. Dignity and respect shown to people had improved but required more action to make sure everyone was protected. Not everyone who spoke with us felt they had been involved in care planning.

The service was not always responsive. Care plans were sometimes confusing or contradictory creating the opportunity for staff to provide care or treatment inappropriately. End of life care planning required further improvement to ensure all people’s needs and wishes were respected. Complaints had been logged but information about investigations and outcomes was not available.

The service was not well led because people remained at risk when insufficient improvements were made following our last inspection. Auditing and oversight checks did not pick up on issues highlighted by inspectors. Feedback had not always been used to drive improvement.

Staff reported a poor culture but were beginning to feel more supported.

Several improvements were found during this inspection. Recruitment checks and systems had been modified to ensure suitable applicants were employed. Information about Do Not Attempt Resuscitation (DNAR) orders was now available to all staff and was included in handover documents for ease of reference. Personal Emergency Evacuation Plans (PEEPs) had been updated to include current information about people’s mobility and capacity.

Medicines, aside from creams, continued to be safely managed and audits of them had ensured standards were maintained. Fire safety checks and routine maintenance checks had been regularly carried out. There were some adaptations to the service to make it suitable for older people or those living with dementia.

Positive feedback was received about staff, and our observations showed mostly gentle and patient interactions. Independence was promoted whenever possible and people said they enjoyed activities and entertainment provided.

The provider made statutory notifications to the CQC. The service notified the Commission of incidents and events that they were legally required to.

It is a requirement that the provider displays their CQC rating at the service and on every website maintained by or on behalf of them. Although the rating from the last inspection was conspicuously displayed at the service, the provider’s website showed the rating for Horncastle Care Centre and not Horncastle House.

We found breaches of nine 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 action when this has been completed.

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.

Horncastle House 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. Horncastle House accommodates up to 43 people in one adapted building. There were 30 people using the service during our inspection. Horncastle House provides nursing care to older people; some of whom are living with dementia.

Since our last inspection of Horncastle House, services operated by the provider had been subject to a period of increased monitoring and support by commissioners. As a result of concerns raised about other locations operated by the provider, the provider is currently subject to a police investigation. There has been one safeguarding concern made about Horncastle House which is being investigated. There have been no specific criminal allegations made about Horncastle House at the time of our inspection. However, we used the information of concern raised by partner agencies about this provider to plan what areas we would inspect and to judge the safety and quality of the service. Since May 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find. Our findings from inspections of other locations operated by the provider also informed the planning of the inspection of Horncastle House.

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 (CQC) 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. The former registered manager had left in September 2017 and their deputy had taken over the management of the service. This manager had applied to CQC to become registered as the manager at the time of this inspection, but no decision had yet been made about their application.

Horncastle House was last inspected in December 2015. At that inspection it was rated as 'Good' in every domain and overall. At this inspection, there had been a marked and significant deterioration in the safety and quality of the service which had not been picked up or remedied by the provider. As a result we found multiple breaches of Regulations across all areas we inspected.

Risks to people had not been robustly assessed and mitigated. This included risks associated with medical conditions, choking, challenging behaviour, the environment, fire evacuation plans, prescribed creams and falls.

Investigations into safeguarding concerns had not identified continued risks to people. Accidents and incidents were documented but follow-up actions were not consistently taken by staff in line with directions in order to reduce the risk of re-occurrence.

There were not always enough staff deployed to meet people’s needs. Training and knowledge of staff deployed was lacking in some areas. Recruitment files did not contain enough information to assure the provider about staff’s employment histories.

People’s healthcare was not properly considered in the development of care plans. Wound care was not appropriately managed and food and fluid intake had not been monitored to ensure records about it were correct and that people remained hydrated.

The service was not meeting the requirements of the Deprivation of Liberty safeguards and Mental Capacity Act 2005 because capacity assessments for people were not decision-specific.

Although staff were kind and gentle, people’s dignity had not been considered appropriately. People were not all encouraged to be independent where possible. People did not feel involved in their care planning and risk assessing.

Care planning was not person-centred in regard to people’s individual health conditions or risks, but information about people’s life histories had been collected. End of life care planning did not focus on people’s preferences and wishes.

Although concerns were logged and investigated by the manager, the provider’s complaints policy was not being operated effectively.

The provider had not ensured that feedback from CQC about some of their other services was used to improve standards as we found similar concerns at Horncastle House than had been identified at other locations operated by the provider. The manager of Horncastle House responded to our findings during and after the inspection but there had been insufficient proactive auditing to highlight any shortfalls and put them right before our inspection.

Safety checks on equipment and utilities had been regularly carried out and documented.

People had access to a range of care professionals such as podiatrists, GPs, dieticians and opticians. Adaptations had been made to the premises to make it suitable for older people/those living with dementia. Staff treated people with kindness and relatives said they felt well-informed about their loved one’s care and progress. A range of activities were available to people.

Staff said they had faith in the new manager. The provider displayed their rating and made statutory notifications to the CQC. The service notified the Commission of incidents and events that they were legally required to and had displayed their CQC rating.

We found eight 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 action when this has been completed.

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.