Archived: Wyvern Lodge

Updated 6 October 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.

Unannounced, daytime inspections took place on 18, 19, 23 and 26 May 2016. On 23 May 2016 we also conducted an unannounced night visit commencing 10pm and finishing at midnight. At each visit there were two inspectors, with three inspectors in total. On the 18 and 19 there was a specialist professional advisor nurse. The nurse was a specialist in elderly care. This was a comprehensive inspection and was brought forward from the planned inspection date due to many concerns being raised with CQC.

Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. Due to concerns raised the inspection was brought forward so a PIR was not available. We took this into account when we inspected the service and made the judgements in this report. We also looked at paperwork from the local authority and other intelligence we held internally about the home.

We spoke with seven people that lived at the home. We spoke with the registered manager, provider and five staff members. We spoke with three visitors including relatives and a health worker. We also spoke with three health and social care professional on the telephone during the inspection.

We looked at six people’s care records and observed care and support in communal areas. 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 looked at five staff files, rotas to show which shifts staff were working, quality assurance audits and supervision records, health and safety paperwork, medicine administration records, daily logs, incident records and a selection of the provider’s policies.

Following the inspection we asked the provider to send us a copy of a service record for the lift in the home and their action plan addressing all the concerns. The lift service record was sent incomplete. A further request was made for the complete certificate but we did not receive it. An action plan was received but it was basic, did not address all concerns and did not mitigate all the risks to people.

Updated 6 October 2016

This was the first inspection for Wyvern Lodge under a new provider. Wyvern Lodge had 11 people living in the home, but during the inspection one of the people went into hospital and remained there. Wyvern Lodge was set over three floors. The ground floor had five bedrooms, two toilets and a bathroom, along with two communal lounges, a laundry room, a dining area, kitchen and access to the outside garden and patio area and the manager’s office. The first floor had four rooms, an airing cupboard and toilet and the second floor had five bedrooms. Not all bedrooms had en-suite shower rooms.

This inspection was brought forward because serious concerns had been raised. These included poor staff levels, concerns about the management of the home, cleanliness of the home, people not getting enough to eat, safeguarding procedures not being followed, untrained staff administering medicines, the recruitment procedures for new staff not being robust and lack of staff training. There were four daytime unannounced inspections on 18, 19, 23 and 26 May 2016. Each inspection was carried out by two inspectors. On the first two days a specialist advisor nurse was present. The nurse had a background in elderly care. During the inspection further concerns were raised about staff levels at night so a night time inspection took place between 10pm and midnight by two inspectors.

There was a registered manager in post for five months but had been in post as an unregistered manager for three months previously. 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.

People had not been kept safe. There was a lack of understanding, by the registered manager and staff, about how to keep people safe. Risks to people were not properly assessed, reviewed or managed. There were no systems in place to ensure people were kept safe when concerns were reported.

Some areas of medicines management were not safe. Staff recruitment was not managed safely. Accidents and incidents were not always recorded or followed up to ensure people’s safety or improve their care. Health and safety checks on the home were not always carried out which put people at risk.

Some people thought staff were kind and caring. There was a lack of social interaction because most interaction was task driven to meet people’s basic needs. Staffing levels were inadequate to ensure people’s needs were being met and they were kept safe. At times the staff levels were putting people at risk of harm. Staff did not have clear guidance about their roles and responsibilities.

Some people had access to health care professionals. However, people with specific medical conditions had not been seen by specialists. People’s legal rights in relation to decision making and restrictions on their liberty were not upheld.

People did not have a choice of nutritious meals and drinks. Some people’s diets were very poor placing them at risk of malnutrition. Other people were at risk of their health being compromised because the meals were not appropriate for their medical conditions.

Most staff had not received adequate and up to date training to keep people safe. Staff were completing assessments and tasks without the correct training. At times, this was putting people at risk of receiving unsafe care based on incorrect information. Staff were not supervised regularly.

Some people did not have any formal system to communicate their wishes or feelings. People were therefore unable, and had not been supported to express their views about life in the home. There were limited opportunities for people to express their views on the care being received. Apart from one complaint, concerns and complaints had not been listened to or responded to. Some people gave up complaining because nothing happened when they did.

People did not receive personalised care which was responsive to their needs. Care planning was confusing and at times out of date. Plans were not reviewed and did not reflect people’s current needs. Some records could not be located during the inspection; there was no evidence these records had ever been completed.

The home had been extremely poorly managed. There had been a chaotic approach to management systems, structures and record keeping. The provider had not completed any governance or auditing of the service. There had been a lack of action when the home failed to improve in identified areas. Shortfalls found by external agencies had not always been acted upon. During the inspection both the provider and registered manager left the home. The registered manager was not contactable even to most staff.

There had been a failure to operate the home in an open and transparent way or in accordance with the law. Significant events which adversely affected people’s safety and welfare had not been reported to either the CQC or other authorities such as the local authority safeguarding team. This had severely compromised people’s welfare and safety.

We raised our concerns about what we found during our inspection with the provider. Over the four days of our inspection the provider failed to take action in response to our concerns or mitigate the major risk to people with regard to their health, safety and well-being. The provider did not take any action to ensure people who lived at Wyvern Lodge were treated with care, respect and dignity and lived in an environment that was caring, fit for purpose, free from risk and safely staffed.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of The Care Quality Commission (Registration) Regulations 2009.

As a result of our findings we applied to Weston-Super-Mare Magistrates Court for an order to urgently cancel the provider’s registration under our powers set out in section 30 of the Health and Social Care Act 2008. The Court ordered that the provider’s registration be cancelled on 27 May 2016. The home was closed on 27 May 2016.