This inspection took place on 13 September 2017 and was unannounced.Smallbrook Care Home is a care home providing support to up to 41 people who are living with dementia. The home specialises in supporting people living with dementia and there is a unit for people living with early onset dementia. This unit supports people who are under 65 and have been diagnosed with dementia. At the time of our inspection the home was providing support to 35 people.
There was a registered manager in post but they were on planned leave at the time of inspection. 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.
Our last inspection was in April 2017 where we identified one breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we found that the provider had not taken enough action to resolve this breach of regulation. We also identified a further nine breaches of regulation. We found that the provider was in breach of regulations 9, 10, 11, 12, 17, 18, 19 and 20 and 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.
We will be requesting information from the provider about specific incidents involving people to ensure that there had been no instances of avoidable harm.
People did not receive safe care. Responses to incidents were not robust which meant that where people had suffered falls, the underlying risks were not managed causing incidents to occur again. The provider was not always proactive in identifying risks and staff were not clear on how to manage individual risks to people. We also identified that important information was missing from medicines records and safe medicines management practices were not always followed.
There were not enough staff at the home to safely meet people’s needs. After the inspection, the provider increased staffing levels in response to our findings. However, the provider will need to ensure they are able to calculate staffing numbers based on people’s needs. There was information missing from one staff file which showed that recruitment checks were not always robust enough to ensure that people were supported by safe staff. The provider took action following our inspection and assessed the risks relating to the missing information from this staff file, however this had not been done proactively.
At our inspection in April 2017, staff were not always raising safeguarding incidents with management. At this inspection we found that incidents were being reported to management and to the local safeguarding team. However, staff were not clear on where they could raise safeguarding concerns outside of the organisation so the requirements of this regulation had not been met.
Staff lacked the training to meet the complex needs of the people that they supported. As a specialist care home for people living with dementia, people’s needs often required specialist interventions from staff. We found evidence that staff lacked this specialist training and did not respond appropriately to people’s behavioural needs.
People’s legal rights were not protected because staff did not follow the guidance of the Mental Capacity Act (2005). Where restrictions were placed upon people, the correct legal process was not followed. Staff and management lacked an understanding of how to apply restrictions in line with the Mental Capacity Act (2005).
Care lacked personalisation and was not always provided in a way that reflected people’s needs and preferences. We saw instances where staff failed to promote people’s dignity when providing care. People’s dietary needs were met but we noted this was not always done in line with people’s routines and preferences. There was a lack of choice on offer for people.
There was a lack of leadership and governance at the home. The registered manager was on planned leave at the time of inspection. The arrangements for management cover had not worked and an assistant manager had left. There was a lack of support and coaching for staff and this was reflected in the care that they provided. Auditing systems were not robust enough to identify the concerns that we found on the day of inspection. Where improvements had been identified through audits, these had not always been actioned. The provider had also failed to notify CQC of important incidents and events.
People had access to a range of activities and we observed people and staff interaction positively. Staff respected people’s privacy when providing support. Relatives knew how to complain and the provider kept a record of complaints but did not identify patterns and themes. We recommended that the provider reviews their systems for analysing complaints.
You can see what action we told the provider to take at the back of the full version of the report.
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.