Archived: Horizon Close

Updated 18 July 2019

The inspection:

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was prompted in part by notifications of incidents following which people using another of the registered services sustained a serious injury. We wanted to check that lessons learnt from these incidents had been shared across all the care homes on the Glenside site.

The information shared with CQC about an incident indicated potential concerns about the management of risk of unsafe medical intervention. Other incidents indicated potential concerns about the management of risk of unsafe clinical management. This inspection examined those risks.

Inspection team:

This inspection was carried out by two inspectors, a specialist advisor, pharmacist and an assistant inspector. There were three inspection managers on site overseeing the inspection.

Service and service type:

Horizon Close 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.

The service did not have a manager registered with the Care Quality Commission. The registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. Despite CQC informing and reminding the provider, an application for a registered manager has not been submitted. This meant the provider was failing to comply with the conditions of their registration.

Notice of inspection:

The inspection took place on the 30 April and 1 May 2019. The first day of the inspection was unannounced.

What we did:

Before the inspection we assessed the information, we hold about the service. We looked at notifications, previous inspection reports and the information professionals shared with us.

During the inspection we looked at the care records of one person in depth, accidents and incident reports. Audits and quality assurance reports.

Updated 18 July 2019

About the service:

Horizon Close 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.

Its aim is to provide maintenance and rehabilitation programmes for adults with long-term neurological conditions. Accommodation is organised into ten bungalows and is one of six adult social care locations which also has a hospital that is registered separately with CQC. Glenside Manor Healthcare Services is not close to facilities and people may find community links difficult to maintain.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

The hospital was closed at the time of our inspection due to flood caused by a major water leak in January 2019. Patients from the hospital were transferred at short notice to some of the adult social care (ASC) locations.

People’s experience of using this service:

The provider failed to apply for an extension of the regulated activity to accommodate hospital patients in ASC locations. Although the provider had notified us of the temporary arrangements for hospital patients while refurbishments were taking place. We informed the provider at the time and at inspections that to continue offering accommodation to hospital patient’s they must submit applications to CQC. This was to ensure hospital patients were cared for in a manner that met the regulated activity.

People were not safeguarded from abuse and were placed at some risk of harm.

Medicines were not well managed and the potential for errors was increased.

The service was not well led. The management had not taken action in response to events that had or could cause harm to people. There have been persistent changes of senior managers. There was a lack of regulatory response from the provider.

Rating at last inspection:

The overall rating at the focus inspection dated 7 November 2018 was Requires Improvement. This report was made final on 20 February 2019. The overall rating of this service was changed to Inadequate.

Why we inspected:

This inspection was brought forward due to information of risk or concern about people living in all ASC locations. After the inspections of other ASC locations CQC requested assurances from the provider about the action they would take to improve the service. The responses provided by the provider did not give assurances that the service would improve.

Enforcement:

Following the last inspection we imposed a condition on the providers registration to submit monthly improvement action plans to CQC. The action plans provided did not give assurances that the service would improve.

Follow up: This service has been placed in special measures. 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.

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.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk