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Archived: Harry Sotnick House Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 4 November 2017

We carried out this unannounced urgent inspection of the home on 3, 4 and 5 October 2017. The inspection was prompted in part by notification of two incidents which had occurred in the home. Following the first of these incidents a person who lived at the home died. This incident is subject to further investigation and as such this inspection did not examine the circumstances of this event.

However, the information shared with CQC about the incident indicated potential concerns about the management of risks associated with; a failure to follow professional guidance adequately, the safe monitoring of people’s hydration and nutrition needs, the administration of medicines and the changing needs of people as they move towards end of life care. A second incident reported to CQC did not involve a person who lived at the home; however this raised serious concerns about the risks associated with the management of medicines in the home. All of these identified risks have been examined in this inspection.

The registered provider has an extensive history of non-compliance with the required regulations in this home. You can see the reports which have been published about our inspection program at this home on www.cqc.org.uk .

In December 2016 the home was rated as Inadequate and placed into special measures by the Commission. Two separate conditions were imposed on the registered provider’s registration for this home which required the registered provider to provide information to the commission on a fortnightly basis showing the actions they were taking to comply with all the required Regulations and provide information on the number of agency staff working in the home.

This home was last inspected in May 2017 where we found the home to be compliant with all the Regulations and was fulfilling the requirements of these conditions. However, further work was required to embed good practices in the home. The home was moved out of special measures although the two conditions imposed on the registered provider’s registration of this home remained in place. The registered provider applied to have these conditions removed from their registration on 14 July 2017; however they remained in place at the time of this inspection.

At this inspection we have identified four breaches of the Health and Social Act 2008 (regulated Activities) Regulations 2014.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. 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.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

The home provides accommodation, nursing and personal care for up to 92 older people, most of whom live with dementia. Accommodation is arranged over two floors with stair and lift access to all areas. A third floor provides staff facilities. At the time of our inspection 70 people lived at the home.

A registered manager was in post. 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.

Medicines were not always managed in a safe and effective manner to ensure the safety and welfare of people. Medicines errors had not always been identified or investigated and learned from.

We identified a number of incidents in the home during our inspection relating to the poor clinical knowledge and understanding of registered nurses.

There was a lack of good clinical leadership in the home. Nursing staff did not always demonstrate a good understanding of their roles and responsibilities. Where clinical errors had been made learning from these was not always recognised and shared in the service.

Whilst there were safe recruitment practices in the home, there were not always sufficient staff with suitable skills, knowledge and experience deployed to meet the needs of people. There was a high dependency on the use of agency registered nurses in the home.

The risks associate with people’s changing clinical needs were not always assessed and actions taken to mitigate these in a timely way.

We saw there was confusion and misunderstanding about what constituted end of life care in the home; care plans in place and actions taken by staff were not always consistent and appropriate to ensure people received care which was in line with their needs and preferences at the end of their life.

People were cared for in a kind and compassionate way. Their plans of care were mostly person centred.

People were encouraged to interact with each other and participate in a wide variety of stimulating activities and events.

There was a system in place to allow people to express any concerns or complaints they may have, and people had the opportunity to express their views on the quality and effectiveness of the service provided at the home.

Where people could not consent to their care, staff sought appropriate guidance and followed legislation designed to protect people’s rights and freedom.

People received nutritious food in line with their needs and preferences. Food and fluid records were well maintained and people enjoyed the food they received.

Inspection areas

Safe

Inadequate

Updated 4 November 2017

The service was not safe.

People were not protected against the risks associated with medicines. The provider did not have appropriate arrangements in place to consistently manage people's medicines safely.

There were not always sufficient registered nursing staff with appropriate clinical skills and knowledge deployed to meet people’s needs and ensure their safety and welfare.

Staff had an understanding of safeguarding policies and procedures.

Risks associated with people’s care had been identified; however there was a failure of nursing staff to respond to the risk associated with changing clinical needs.

Staff recruited to the home had been assessed as to their suitability to work with people.

Effective

Good

Updated 4 November 2017

The service was effective

Where people could not consent to their care, staff sought appropriate guidance and followed legislation designed to protect people’s rights and freedom.

People received nutritious food in line with their needs and preferences.

Most staff had received training to enable them to meet the needs of people.

Caring

Requires improvement

Updated 4 November 2017

The service was not always caring.

People’s end of life preferences and choices were not always kept under review and acted upon promptly.

People’s privacy and dignity was maintained and staff were caring and considerate as they supported people. People were valued and respected as individuals and were happy and content in the home.

Arrangements were in place to ensure people were involved in planning their care and their views were listened too.

Responsive

Requires improvement

Updated 4 November 2017

The service was not always responsive.

People did not always receive care which was person centred and individual to their specific nursing needs.

There was a wide range of meaningful activities and interactions in the home to reduce the risk of social isolation for people.

A system was in place to allow people to express any concerns or complaints they may have.

Well-led

Inadequate

Updated 4 November 2017

The service was not well led.

Whilst a registered manager was in place there was a lack of strong and effective nursing leadership and accountability in the home. Nursing staff did not have a good understanding of their roles and responsibilities.

Whilst the registered provider had systems in place to monitor and review the quality and effectiveness of the service provided, these had not always been effective in identifying and dealing with the concerns we noted at our inspection.

There was an open and transparent culture within the home and staff felt supported by the registered manager.