Archived: Parkview Residential Home

Updated 27 January 2016

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.

We undertook an unannounced comprehensive inspection on 25, 26 November 2015 and 7 December 2015. The inspection team consisted of two adult social care inspectors and two specialist advisors. One of the specialist advisors had a nursing background; the other was a qualified electrician. Cleveland Fire Service completed a fire safety audit on 25 November 2015. Environmental health officers completed a food hygiene audit on 7 December 2015 and began a buildings inspection.

Before the inspection we reviewed the information we held about the service, including notifications we had received from the provider. Notifications are changes, events or incidents that the provider is legally obliged to send us with the required timescale. We also contacted the local authority safeguarding team, commissioners for the service and the local Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We carried out observations using the Short Observational Framework for inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us. We undertook meal time observations and observations of how staff interacted with people as they went about their work.

We were supported by the registered manager on the first two days of inspection but on the final day they were not available.

We spoke with six people who lived there, two visitors, the registered manager, the deputy manager, the director, the area manager and the quality manager. We also spoke with three senior care staff, three care staff, the activities coordinator and the cook.

We looked at care records for five people and pathway tracked their records. We looked at the medicines records for all people using the service and records relating to the management of the premises.

We also viewed four staff files and four bank staff files, including recruitment, training and supervision and looked at records relating to the quality assurance and improvement of the service.

Updated 27 January 2016

This inspection took place on 25 and 26 November 2015. Following these two days of inspection we requested the provider send us an urgent action plan in response to concerns that we identified. We visited again on 7 December 2015 to check the action they said they had taken. This was unannounced. We last inspected the service on 28 April 2015.

We completed an unannounced comprehensive inspection of this service on 2 and 5 February 2015 and found the provider was failing to meet legal requirements. Specifically the provider had breached Regulations 12, 13, 15 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

During our February 2015 inspection we concluded people were not being protected against the risks of receiving care that was inappropriate or unsafe. People were not fully protected against the risks associated with medicines because the provider did not manage medicines appropriately. The provider did not have effective systems in place to protect people from the risks of exposure to a health care associated infection. People’s rights against inappropriate restriction of liberty were not in place to make the required assessments and applications, in line with Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) legislation. People were not fully protected against the risks associated with unsafe or unsuitable premises.

We undertook an unannounced focused inspection on 28 April 2015 as part of our on-going enforcement activity and to check whether the provider now met legal requirements. However we found continuing breaches of legal requirements. Specifically these related to Regulations 12, 13, 15 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. In summary people were not fully protected against the risks associated with medicines because the provider did not manage medicines appropriately. The provider did not have effective systems in place to protect people from the risks of exposure to a health care associated infection. People’s rights against inappropriate restriction of liberty were not protected because appropriate measures were not in place to make the required assessments and applications, in line with MCA and DoLS legislation. People were not fully protected against the risks associated with unsafe or unsuitable premises.

Parkview Residential Home provides care and accommodation for up to 26 people. On 25 November 2015 there were 17 people using the service.

The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Safeguarding concerns had not been raised in relation to incidents where one person was sleeping in a room where the roof was leaking above their head. Nor was an incident of inappropriate touch between people raised as a concern. The registered manager, despite attending training, did not acknowledge these events as safeguarding incidents and therefore no alerts had been made, meaning people remained in potentially harmful situations.

Risk assessments for the building, equipment and people were ineffective and did not identify risk or control measures to keep people safe.

The building was in a poor state of repair. There were no risk assessments or effective monitoring of the leaking roofs. People were using a bathroom with a draughty window that did not close properly. The registered manager told us people preferred to use this bathroom however the other bathroom was not useable due to the bath hoist being broken.

There was no ongoing maintenance schedule to evidence a rolling programme of repairs for the building or equipment. External exit routes were found to be padlocked which would prevent people leaving in the case of an emergency evacuation; fire doors were compromised and compartments breached.

Care plans contained inaccurate information about people’s care, and the registered manager confirmed the contradictions but did not act to rectify them.

Do Not Attempt Cardio Pulmonary Resuscitation orders were in place for some people but the registered manager had not questioned the content of these which was in breach of the Mental Capacity Act (2005) code of practice.

Staff did not understand the MCA (2005) code of practice. Capacity summary sheets were in place but were not decision specific. Relatives were giving consent when they had no Lasting Power of Attorney in place to give them the authority to do so.

We saw two people asleep during mealtimes; one person’s head was on a cup of tea, the other in a bowl of cornflakes. There were no staff available in the dining area to respond to people’s needs.

Staff were task focused and there were not enough of them to meet people’s needs as detailed in care plans. For example, one person required two-to-one support for transfers; another person needed to be observed whenever mobile and another person was to be observed if presenting with challenging behaviour. This would need four staff but there was only three care staff working at any given time which meant the remaining people were left without supervision or support.

We saw accidents had occurred where people had fallen or hit their head on the dining table. They were attended to by staff who were not trained in first aid nor was medical support sought for people.

There were not enough seats in the dining area for everyone to sit and have a meal together if they chose to do so.

The registered manager failed to recognise, investigate and respond to complaints and in the process failed to follow the provider’s own policy in relation to complaint management.

There was no effective quality assurance process in place. The registered manager did not complete any audits nor did they respond to actions identified on audits completed by the quality manager. There was no system or process to assess quality and drive continuous improvement.

Medicines were managed appropriately.

Staff received supervision and appraisal however some training had not been delivered, such as nutrition and hydration, dignity and respect and first aid.

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.

You can see what action we told the provider to take at the back of the full version of the report.